Musings: Blog of the JAAPA Editorial Board


Blog of the JAAPA editorial board.

Monday, March 3, 2014

Showdown at the OK Corral: Medicaid expansion
Jennifer Coombs, PhD, PA-C
Sick of hearing about the coming changes associated with the Affordable Care Act (ACA)? The rancorous debate in Washington over the last few years has now shifted to a political showdown in individual states. Discussions at our local statehouses, around the office watercooler, and at the kitchen table have focused on the dispute over Medicaid expansion. The showdown metaphor seems apt out West as the debate falls into the category of distrust of the federal government versus acceptance of federal money and potential future political consequences. A deep distrust of “the feds” pervades all of these discussions. Equally important is the politicalizing of the issue—those who support acceptance of Medicaid expansion are seen as accepting “Obamacare.” This is not about healthcare at all, but about appearing politically weak by agreeing with the President.
In local statehouses the issue is not a small one. Political futures will be dashed. Governorships will be gained. The lines are so strongly drawn that compromises are not even being debated. In Utah, where I live, conservatives are in the majority. One would think it would be an easy decision to reject Medicaid expansion in such a homogenous state--which would send a message to Washington about how we feel about the ACA.  Click here to see where your state falls in the expansion debate.
Not so fast. How do you say goodbye to $524 million a year? That takes a special political compromise that makes the TV show “House of Cards” look like an episode of “Sesame Street.” Right now, Arkansas and Iowa are entertaining a potential third way—a privatized Medicaid plan. Whether the Centers for Medicare & Medicaid Services would accept this is yet to be determined.
How did we get here? A bit of history is required. The most famous gunfight in US history was the showdown at the OK Corral in Tombstone, Ariz. The 6-second gunfight consisted of 40 shots fired at a distance of 6 feet. The participants were the sheriff and other lawmen (Wyatt Earp and dentist Doc Holliday, a temporarily deputized healthcare provider turned lawman-gunfighter) against the cowboys, who were considered outlaws. Family, political alliances, money, and power were on the line.
Medicaid began in 1965 as a way of insuring American citizens living in poverty. Although Medicaid started at the same time as Medicare, it differs in many ways. Medicare was developed for those over age 65 years, and is administered by the federal government. Medicaid is administered by the states, financed by a combination of federal and state tax revenues, and is available only to certain categories of poor citizens. The argument over Medicaid expansion is whether to pay for increasing healthcare costs out of our right pocket or out of our left. In other words, the taxes have been collected by the federal government, and then given back to the states—under certain conditions—to insure certain populations of poor citizens.
Another federal/state insurance program for the poor is the State Children’s Health Insurance Program (S-CHIP). The basic feature of S-CHIP and Medicaid is the dance between the federal government and the states in the percentages of funding. Or in percentages of giving back the money that has already been collected through federal taxes. The other important feature is that each state gets more or less money based on its per capita income. Connecticut, New York, and California have the highest per capita incomes and are reimbursed less by the federal government than those states with lower per capita incomes such as West Virginia and Mississippi. 
Other features of Medicaid that are making this debate over Medicaid expansion particularly political is the fact that Medicaid was established as a voluntary program for states with each state deciding what to pay for—again with strong incentives from the federal government. The worry from states with a historically strong distrust of the federal government is twofold:
• Medicaid and S-CHIP are considered entitlement programs that, once instituted, are hard to take away.
• Many people who oppose Obamacare feel this is a thinly veiled attempt to take all healthcare control away from states and make it a centrally controlled federal program.
What happens to the healthcare provider turned lawman-gunfighter? The story of the showdown at OK Corral ends with Doc Holliday surviving the gunfight. However, the shootouts and killings continued between the two sides and the matter was not settled in the least. Doc Holliday ended up dying at age 36, presumably of tuberculosis, in the town of Glenwood Springs, Colo. 
If the metaphor of the gunfight at OK Corral is to be played out, the citizens of states who ultimately reject the federal money may survive the battle over Medicaid expansion, with few winners and many losers. As the lawmen (the feds) fight it out with the cowboys (the states), it remains to be seen whose political futures we will be strengthened and whose will be weakened.
What about the poor and those who would benefit from expanding Medicaid programs to cover households earning up to 138% of the federal poverty level? The plan in states who reject full Medicaid expansion is to set up an alternate state-run exchange for those falling through the gap. In Texas, for example, more than a million people are estimated to fall into this gap. In Georgia, 400,000 fall through the cracks. This may literally cost lives, as a new Harvard University study shows that in states that expanded Medicaid coverage, fewer people died.
The showdown over Medicaid expansion is far from resolved as the gunfight rages on, and the potential for all citizens to be injured in the crossfire continues.

Jennifer Coombs is an assistant professor in the Division of Physician Assistant Studies, Department of Family and Preventive Medicine at the University of Utah School of Medicine in Salt Lake City. The views expressed in this blog post are those of the author and may not reflect AAPA policies.