american rescue plan

Ideology Is Still at the Heart of the Red-State Refusal to Expand Medicaid

Twelve states are still turning down increasingly generous incentives to expand Medicaid. Photo: Joe Raedle/Getty Images

An under-discussed element of the American Rescue Plan (Joe Biden’s COVID-19 relief and stimulus bill) signed into law on March 11 was its effort to make the Affordable Care Act’s Medicaid expansion so painless that the 12 states (Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming) still holding out against it would finally give up, take the federal money, and begin giving uninsured citizens health-care coverage. As the Kaiser Family Foundation explained soon after the law was enacted, the idea was to raise the federal match rate for all Medicaid costs in those states newly agreeing to expand coverage:

[N]ew federal funds under the 5 percentage point bump are more than two times larger than new state expansion costs; this ratio varies slightly across states, from more than one a half times larger in Texas to over four times larger in South Carolina.

In other words, the common complaint from Republican leaders in the non-expansion states (all of whom have GOP-controlled legislatures) that the expansion is some sort of “unfunded mandate” because only 90 percent of the costs are borne by the federal government don’t really have that excuse anymore. Yet so far none of them are exactly rushing to cash in while helping their people stay healthy and alive. USA Today published an overview of where most of these states are on the topic, and it’s discouraging:

A combined 4 million people without insurance could gain coverage if all 12 states acted. That represents more than one-third of the uninsured in those states.

Most are in the South, are people of color, and live in poverty, even though most are in a family with at least one worker, according to the Kaiser Family Foundation, a nonpartisan health research organization.

Republican leaders in Florida, Georgia, Mississippi, North Carolina, and South Carolina don’t seem interested. There’s some interest in Alabama and Texas, but no action yet. The jury’s still out in Kansas and Wisconsin, where Democratic governors favor expansion but legislators may just say no. Expansion got through one chamber of the Wyoming legislature, but not the other. And Republican legislators in South Dakota — who anticipate an expansion via ballot initiative like the ones that pushed other red states across the line — are trying to require a popular supermajority before it can happen.

You can no longer even blame all this churlish inaction on knee-jerk Republican hostility to Obamacare, or Obama himself; we are two presidents past the 44th. At this point it is increasingly clear many Republicans simply want to deny their citizens the benefit of (or as some believe, the dependency on) this very successful public health-care program. It’s not about money, or even partisanship, but about a cruel ideology. It really ought to be a red-hot election issue in 2022 in any state that continues to reject a very sweet offer of federally financed Medicaid expansion.

Ideology Still Drives Red-State Refusal to Expand Medicaid