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Republican Medicaid Wars Miss the Real Issue


Republicans are at it again. Just as they battle with Democrats over things that are relatively unimportant, so they fight with each other. But, as usual, they miss the real issue.

The Patient Protection and Affordable Care Act, otherwise known as the PPACA, the ACA, or Obamacare, was signed into law by Barack Obama on March 23, 2010, after the massive bill (H.R.3590) passed the House and Senate without a single Republican vote. Republicans have tried in vain to repeal Obamacare ever since, but not because they believe in a free market in health care and health insurance.

Obamacare is a collection of tax increases and a series of “reforms” to the nation’s health-care and health-insurance system. The first requirement of Obamacare (a 10-percent tax on indoor tanning services) took effect in 2010. Most of its reforms were scheduled to take effect beginning in 2014, (but some were delayed), and its final provisions will take effect in 2020 — years after Obama is out of office. The most infamous provision of Obamacare is, of course, the individual mandate that every American not covered by health insurance must purchase it or pay a penalty. There is also an employer mandate that all employers with 50 or more employees must offer health insurance to their full-time workers or pay a penalty.

The stated purpose of the ACA is to “provide affordable, quality health care for all Americans and reduce the growth in health-care spending, and for other purposes.” Those “other purposes” include changes to the Medicare payment system, the creation of health-insurance exchanges, new requirements for health-insurance companies, and the expansion of Medicare coverage for most low-income adults to 138 percent of the federal poverty level.

Medicaid is government-funded health care for poor Americans of any age and people with certain disabilities. It is the primary source of health-insurance coverage for low-income populations and nursing-home long-term care. Medicare is a means-tested program jointly financed by the federal government and the states, but designed and administered by the states. According to the Kaiser Family Foundation, Medicaid covers about 70 million Americans, finances about 16 percent of total personal health spending in the United States, and costs taxpayers about $450 billion a year.

Just as states are not required to participate in the Medicaid program, so they are not required to participate in the Obamacare Medicaid expansion. In the Supreme Court case of National Federation of Independent Business v. Sebelius (2012), the Court held that states cannot be required to participate in the ACA Medicaid expansion and that those that refuse cannot lose their current Medicaid funding. But even though all states do participate in Medicaid, only 31 of them have expanded their Medicaid programs under the ACA. In those states, the federal government fully pays for the expansion through 2016, but by 2020 will pay only 90 percent.

After the Supreme Court NFIB v. Sebelius ruling, several states with Republican governors initially decided against expanding Medicaid coverage in their states. But now a Republican Medicaid war is heating up between more-pragmatic Republicans, especially state governors, and more-ideological Republicans, especially those in Congress who keep voting to repeal Obamacare. According to a recent New York Times article,

In Arizona, Arkansas, Indiana, Iowa, Michigan, Nevada, New Jersey, New Mexico and Ohio, Republican governors have expanded Medicaid under the health care law or defended past expansions. In South Dakota, Tennessee and Utah, Republican governors are pressing for wider Medicaid coverage. And Republican governors in a few other states, including Alabama, have indicated that they are looking anew at their options after rejecting the idea in the past.

A week after Republican Sen. John Thune of South Dakota argued that Obamacare was “unpopular and unaffordable” and voted to repeal major provisions of the ACA and end its expansion of Medicaid, the state’s Republican governor, Dennis Daugaard, “announced that he wanted to make 55,000 additional South Dakota residents eligible for Medicaid under the law.” Said Daugaard, “I know many South Dakotans are skeptical about expanding Medicaid, and I share some of those sentiments. It bothers me that some people who can work will become more dependent on government.” But then he said that “we also have to remember those who would benefit, such as the single mother of three who simply cannot work enough hours to exceed the poverty line for her family.”

In Utah, Republican governor, Gary Herbert, has been trying for two years to expand Medicaid, but the state’s two Republican senators, Orrin Hatch and Mike Lee, are opposed. Said Lee, “Medicaid’s abysmal track record of failing our most vulnerable populations will only get worse as millions of new, able-bodied adults join the program.”

Republicans, as usual, are missing the real issue. No Republican in Congress is against his state’s expanding Medicare because of any philosophical objection he has to the Medicaid program. No Republican in Congress has introduced a bill to abolish Medicaid. No Republican in Congress has suggested that Medicaid be eliminated. No Republican in Congress has called for substantial cutbacks to be made to the Medicaid program. No Republican in Congress has recommended a freeze in Medicaid spending. No Republican in Congress has proposed a plan for the gradual elimination of Medicaid. No Republican in Congress is opposed to the government’s forcing some Americans to pay for the health care of other Americans.

All we ever hear from Republicans in Congress is that Medicaid needs to be “reformed” and “strengthened.”

But not only is providing health care for the poor, needy, aged, and infirm not a proper function of government, not only is making health care more affordable not a proper function of government, not only is providing a health-care safety net not a proper function of government, and not only is expanding access to health care not a proper function of government, there is nothing in the Constitution — which Republicans in Congress claim to revere and follow — that authorizes the federal government to have a Medicaid program.

But it’s not just the Medicaid program. Medicaid is just part of a much broader issue. It is not the proper role of government and it is not constitutional for the U.S. government to have anything to do with health care or health insurance. That means not only no Medicaid, but also no Medicare, SCHIP, Obamacare, National Institutes of Health, or Department of Health and Human Services. It also means no federal laws, mandates, regulations, guidelines, licensing, standards, oversight, or restrictions that have anything to do with health care or health insurance. And because no American has a right to the resources of another American, no matter how low his income or how badly he needs medical services, there should be no government funding of health care or government subsidies for health insurance.

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