| March 6, 2013

Medicaid Expansion: Principle, People, and Peril

Joseph Sobran, the late conservative/libertarian author and columnist, loved people in the flesh, rather than as symbols. He was often misunderstood. I usually but not always agreed with Joe. I honor his memory, and the rigor with which he looked at policy in late 20th century America.

For decades, I learned a lot from watching Sobran, including the perils of making a point powerfully but without nuance. Still, I loved and respected the man. He became a pal on my first-ever visit to New York City and the offices of National Review magazine, back in the day.

Joe once wrote: “Liberalism, of course, professes to speak for ‘the poor,’ even though, given a choice between the poor themselves and a program whose real effect is to hurt the poor, it will choose the program.”

Ouch. That is well put, but is it too harsh?

Maybe not.

In an analysis for the Journal of Health Politics, Policy and Law, Joseph Antos of the American Enterprise Institute writes that, because many health care providers are reluctant to take Medicaid patients, “poor Americans have faced ‘a substantial vacuum in actual access to health care’ despite Medicaid’s coverage guarantee.”

Antos adds, “Putting millions of additional people into a program that has been struggling with access to care for the past forty-five years is likely to result in worsening access for those who are currently enrolled in Medicaid.”

Michael F. Cannon of the Cato Institute notes that expanding Medicaid makes these new Medicaid patients (some of whom already had private health insurance, by the way) “dependent on government for their health care, and thus would expand the constituency for more government spending and higher taxes”—all while providing them inferior access to health care.

Back here in the promised land, the Oklahoma State Medical Association (OSMA) worries that the addition of 200,000 people to Medicaid rolls in 2014, which could have happened if Gov. Fallin hadn’t resisted the Medicaid expansion, would crater any ability to care for patients, poor or otherwise, in a sustainable way.

Oklahoma already ranks near the bottom in physician-to-patient ratios. OSMA executive director Kenneth King told Jennifer Lubell of, “It’s pretty cynical to say, ‘Yes, you’ve got coverage, but you can’t see a doctor for two years.’ So we’re worried about the workforce issue.”

Health-care researchers Avik Roy and Grace-Marie Turner put it succinctly: “Medicaid harms the poor.”

The Medicaid program is so badly broken that it actually harms the people it is intended to serve. Mountains of clinical literature show that, on average, patients on Medicaid have poorer health outcomes than those with no insurance at all. The largest such study by far, conducted by surgeons at the University of Virginia, examined outcomes for 893,658 individuals undergoing major surgical operations from 2003 to 2007. It found that patients on Medicaid were 13 percent more likely to die in the hospital after surgery than those with no insurance, even when adjusting for age, gender, income, region, and health status. Medicaid patients were 97 percent more likely to die than those with private insurance.

This is because the Medicaid program pays doctors and hospitals far less than private insurers do. … As a result, many doctors refuse to take Medicaid, and when Medicaid patients can’t get predictable access to care, their cancers go undiagnosed and their heart conditions go unmanaged. Access to specialists is particularly challenging. When Medicaid patients finally do get care, their diseases are often more advanced and more difficult to treat. This is worse than having no insurance at all, because uninsured people pay out of pocket, which doctors accept, compared with Medicaid, which underpays doctors and requires lots of form-filling and arguing.

Despite these compelling facts, the case made for Medicaid expansion is usually made in moral terms. Gov. Scott and others who have switched sides have copied the rhetoric of the political Left, saying it is immoral to leave anyone behind when it comes to health care.

Is it more immoral to destroy a system that works, however imperfectly, for most Americans, and replace it with a system that will collapse, one in which the poor and everyone else will witness unprecedented stress and strain?

Gov. Fallin put it less emotionally in late February: “Choosing not to expand Medicaid as proposed in [the Affordable Care Act] was the right decision for Oklahoma. The president’s expansion is unworkable and unaffordable for our state. Some estimates show expanding Medicaid would cost Oklahoma an additional $689 million.

“Instead, we are focusing on an Oklahoma plan to improve the health of our citizens, lower the frequency of preventable illnesses like diabetes and heart disease, and improve access to quality and affordable health care.”

In February, State Budget Solutions—a national group focused on unfunded liabilities, state debt, and pension reforms—honored Fallin with its “Real Leader Award” for her decision not to expand Medicaid.

It won’t be easy, but there might still be a state, and an economy, where people, including the poor, can fashion better lives for themselves, in ways they deem best, and in keeping with American traditions of personal liberty.

For months, in long, heartfelt, and sincere political and policy discussions with friends on the Left—people I love and respect—the issues of Obamacare and Medicaid expansion have been the main subject matter.

I do not want to believe that Sobran’s maxim is true of these friends, but I feel it is true of the broader statist impulse that advances every year, every month, every week, and every day in my beloved country.

In America’s present zeitgeist, given a choice between “the poor”—as individuals, people who actually have hearts, minds, souls, and possibilities—and a public policy that puts programs in charge of people, the program will win.

This expansion of government power is without prec-edent. Even if the Supreme Court says that taking control of the health industry is permitted under the Constitution, even if the Court calls the individual mandate a tax rather than a penalty, even if it is asserted that a federal statute enacted dubiously trumps more than two centuries of constitutional limits on federal government power—this expansion of compulsion is unmatched in our federalist history.

Government is limited because human beings are flawed creatures.

There is no committee that can rationally decide in advance what is best for any one of us, no panel of experts that can dictate to families how the final days or weeks of their loved ones should be spent, no possibility that centralized treatment of diverse human belief systems can be truly just.

Questions of finance aside, our government is assuming powers that belong with individuals, communities, and “mediating institutions” such as churches and other support networks. On that path lies cultural disintegration.

In the end, the entire structure of the Affordable Care Act violates the spirit of the Constitution, American traditions, and the accumulated wisdom of past generations, who understood that excessive power corrupts.

Patrick McGuigan (M.A. in history, Oklahoma State University) is editor of He is the editor of seven books on legal policy, and the author or co-author of three books, including Ninth Justice: The Fight for Bork.

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