Critics of Medicaid Expansion Demonized, Ignored

Dan Greenberg Commentary

Critics of Medicaid Expansion Demonized, Ignored
Dan Greenberg

Whether to expand Medicaid was, and continues to be, the most divisive and hotly debated question of Arkansas’ 2013 legislative session. Regrettably, readers of Gwen Moritz’s recent column (“The Dangers of Demonization,” July 1) will only learn that she finds this question unworthy of serious discussion. Instead, Moritz explains that those who opposed Medicaid expansion did so “simply to make a point,” but that those who favored it “put people above ideology.” Those who agreed with Gov. Beebe that Medicaid expansion was a “no-brainer” will find Moritz’s perspective convincing; others will find it less so. I would respectfully suggest to Moritz that the following questions, which an uncritical advocacy of Medicaid expansion invites, pose difficulties for her view.

• Moritz's column describes Medicaid expansion as "turning down hundreds of millions of taxpayer dollars every year." The reality is a bit more complex, because it is more accurate to weigh any proposal's costs and benefits against one another. In five years or so, thanks to Medicaid expansion, Arkansas state taxpayers will annually, on net, have to provide for several hundred millions of dollars in new spending obligations in an already strained state budget. Should we plan to do this through cuts to existing programs, through tax increases or a combination of both? Or should we hope that economic growth will solve this problem for us?

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• Are the advocates of Medicaid expansion in Arkansas familiar with the outcome of Oregon's Medicaid experience? Oregon's experience — which is very much like a scientific experiment, complete with an experimental group and a control group — strongly suggests that there is no difference in actual, physical health outcomes between those covered by Medicaid and for those with no coverage at all. To repeat: that means Medicaid enrollment doesn't improve physical health at all. Why should we expand Medicaid if the significant amount of resources it will take doesn’t have significant effects on people’s physical health?

• One of the biggest justifications for "private option" Medicaid expansion was the easing of the burden that Obamacare's employer mandate created. Given that the Obama administration announced earlier this month that it would delay imposing the mandate for at least one year, how much does this weaken the case for Medicaid expansion? Is it reasonable to consider the possibility that the White House will extend its one-year delay even further into the future? Would such a delay weaken the case for the private option even more?

• More generally, does the case for the private option depend on the White House's successful implementation of Obamacare? Is the current state of Obamacare implementation on track? How much credence should we give to the GAO's report that "critical" activities to create federal Obamacare exchanges — the ones that are supposed to start enrolling people in less than three months — have not been completed? How relevant is it that the White House has already discarded implementation of the "long-term care" component of Obamacare, and that it has delayed not only the creation of Obamacare small-business exchanges but also the basic health plan for those who aren't Medicaid-eligible? At what point are we justified in concluding that significant implementation delays and difficulties will likely continue?

• Moritz suggests that repealing Medicaid expansion would be "a futile gesture and worse than an empty one" that wouldn't "do anything at all to the federal law, the individual mandate or new employer requirements." Could a state's refusal to expand Medicaid make it more likely that Obamacare would eventually be repealed?

• Advocates of the private option claimed that the competition it required would push prices down and save taxpayers money. If clients won't pay anything to enroll in the private option, how does price competition occur? If competing providers must supply all the services that Medicaid providers must, how does competition in service provision occur? If we begin by envisioning a competitive health insurance market but then withdraw price competition and service provision competition from it, what competitive elements remain?

I have had high regard for Gwen Moritz ever since she and I worked together at the Pine Bluff Commercial in the 1980s. But her suggestion that those who opposed Medicaid expansion are simply motivated by irrational spite against Obamacare was not her finest hour. I would have expected the author of an editorial entitled “The Dangers of Demonization” to provide something more than wholesale dismissal (or, dare I say it, demonization) of the perspective of those with whom she disagrees. In my opinion, Medicaid expansion is currently endangered — both politically and substantively — largely because its architects and advocates so casually ignored any serious criticism of it.

Dan Greenberg is president of the Advance Arkansas Institute ( Email him at