# Why are so many states not taking the Medicaid Expansion? **URL:** \ **Category:** Great Debates\ **Created:** [October 4, 2013, 7:03pm UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384 "2013-10-04T19:03:09Z")\ **Posts on this page:** 20\ **Page:** 1
**Author:** ![John\_Stamos\_Left\_Ear](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/john_stamos_left_ear/32/3198_2.png) [@John\_Stamos\_Left\_Ear](https://boards.straightdope.com/u/John_Stamos_Left_Ear)\ **Post date:** [October 4, 2013, 7:03pm UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/1 "2013-10-04T19:03:09Z")
When the Supreme Court ruled that the mandate was not unconstitutional, the headline was that ObamaCare was in full effect. However, the Supreme Court did, in fact, put some limitations on the Affordable Care Act: > [@](#): > > In addition to requiring citizens to buy health insurance, the law also expanded Medicaid and tied federal funding to that expansion of state programs. In order to provide insurance to more poor people, the law said that states who did not accept the Medicaid expansion would risk losing existing Medicaid funds. > > Today the Court said that as long as states who chose not to participate in the law’s expansion of Medicaid do not lose existing funds the Medicaid the expansion is constitutional The vote was 5-4 with Chief Justice John Roberts joining the liberal bloc. > The end result could be that more states opt out of the Medicaid expansion, which won’t be enacted until 2014, and the law could end up insuring fewer currently uninsured Americans. > > [ABC News](http://abcnews.go.com/blogs/politics/2012/06/supreme-court-curbs-health-reform-expansion-of-medicaid/) Now, the logic of the court makes me wonder how on earth it was constitutional that [states had to agree to the 55 MPH speed limit on highways if they desired to receive federal funding for highway repair](http://en.wikipedia.org/wiki/National_Maximum_Speed_Law#Enactment). But that’s a philosophical argument for another time. (And another court.) Since that ruling was handed down, states have, almost entirely on partisan lines, [either accepted or rejected the expansion](http://www.advisory.com/Daily-Briefing/Resources/Primers/MedicaidMap), with a few undecided as the deadline approaches. [As of last month](http://www.minnpost.com/christian-science-monitor/2013/08/medicaid-expansion-why-some-gop-governors-are-opting-after-all): > [@](#): > > 25 states are expanding their Medicaid programs, 21 states are not, and five are still debating the issue. Of the 21 states opting out of expansion, 20 are led by Republican governors and one, Missouri, by a Democrat, Gov. Jay Nixon. In Missouri, a Republican-controlled legislature is responsible for the state’s rejection. The narrative concerning states rejecting the expansion all seems to point to how Republicans at the state level are making a bad choice - they are passing up free money in times when most states can use all of the income they can get to help with their budgets. And this partisan move doesn’t just get measured in terms of dollars and cents; their decision is hurting the residents of their states, literally killing the people who are most in need of the expansion. Now, Republican state leaders are not going to come out and say “We are making bad decisions for our state based purely on ideology.” But then I see [this quote from Georgia Governor Nathan Deal](http://www.timesfreepress.com/news/2013/sep/15/tennessee-georgia-poor-left-behindobamacare-to/): > [@](#): > > “Even though the federal government promises to pay 100 percent for the first three years and 90 percent thereafter, I think it is probably unrealistic to expect that promise to be fulfilled in the long term, simply because of the financial status that the federal government is in,” he said. Yeah, he really did just say that he won’t accept the Medicaid Expansion because he thinks the US government is lying to him. :rolleyes: So I create this thread looking for more than just putting party before red state. I look for actual reasons why a responsible governor would reject Medicaid Expansion into their states. If even a Conservative hardliner such as Arizona Gov. Brewer - she of the infamous finger-pointing at Obama after he got off his plane, she who was against ObamaCare - saw enough positives for her state by accepting the expansion that [she alienated Arizona Republican lawmakers](http://www.huffingtonpost.com/2013/06/13/arizona-medicaid-expansion_n_3430371.html) and conservative pundits across the country by going so far as to veto all legislation until the Arizona Congress passed a bill addressing it. That is how important it was to her. So you’re a state governor. Why on earth would you not accept the Medicaid Expansion? “Because I am a Republican” is a childish reply. “Because my country is lying about paying for it” is even worse. Is there a reason that makes any sense? ---
**Author:** ![SmartAlecCat](https://avatars.discourse-cdn.com/v4/letter/s/67e7ee/32.png) [@SmartAlecCat](https://boards.straightdope.com/u/SmartAlecCat)\ **Post date:** [October 4, 2013, 8:56pm UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/2 "2013-10-04T20:56:25Z")
They think they will eventually be on the hook to pay for it. ---
**Author:** ![Kent\_Clark](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/kent_clark/32/105_2.png) [@Kent\_Clark](https://boards.straightdope.com/u/Kent_Clark)\ **Post date:** [October 4, 2013, 8:59pm UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/3 "2013-10-04T20:59:21Z")
I was working on some healthcare related issues in Missouri back in 2003 – before anyone had even heard of Obama – and there were hardline conservatives in the state legislature who wanted to get rid of Medicaid altogether. They’ve been working for years to figure out how to make it so no one qualifies for Medicaid, and if someone should get in, to audit them for fraud every year. ---
**Author:** ![John\_Stamos\_Left\_Ear](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/john_stamos_left_ear/32/3198_2.png) [@John\_Stamos\_Left\_Ear](https://boards.straightdope.com/u/John_Stamos_Left_Ear)\ **Post date:** [October 4, 2013, 11:26pm UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/4 "2013-10-04T23:26:17Z")
> [@SmartAlecCat](#): > > They think they will eventually be on the hook to pay for it. Is there evidence that they have reason to worry? Has the USA told states they would get funds for something and then reneged? Recently? ---
**Author:** ![Ca3799](https://avatars.discourse-cdn.com/v4/letter/c/9f8e36/32.png) [@Ca3799](https://boards.straightdope.com/u/Ca3799)\ **Post date:** [October 4, 2013, 11:39pm UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/5 "2013-10-04T23:39:01Z")
My Gov thinks the expansion will cause ‘a culture of dependency’ and also worries that as the Federal contribution fades over time, the State will have to pick up the slack in the future funding of the Medicaid expansion program. Since my Republican Gov is of the ‘smaller governement’ mindset, he also believes in cutting taxes. Less tax money also means fewer programs. So, ultimately, he does not want the program (or, many programs, including the EPA, education, and the even Department of Commerce) expanded. Yes, he is a tea-nut. ---
**Author:** ![Marley23](https://avatars.discourse-cdn.com/v4/letter/m/45deac/32.png) [@Marley23](https://boards.straightdope.com/u/Marley23)\ **Post date:** [October 4, 2013, 11:58pm UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/6 "2013-10-04T23:58:50Z")
Spite. ---
**Author:** ![bump](https://avatars.discourse-cdn.com/v4/letter/b/7c8e57/32.png) [@bump](https://boards.straightdope.com/u/bump)\ **Post date:** [October 5, 2013, 12:15am UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/7 "2013-10-05T00:15:11Z")
I think it’s entirely legitimate for states to question and even refuse Federal programs and mandates that are not completely funded by the Federal government in perpetuity. Why should the states agree to even pick up 10% of the tab? It’s not _their_ program, but the Federal Government’s, after all. Mind you, I’m all in favor of single-payer universal healthcare, and even in favor of a specific tax levied to fund it. But Obamacare ain’t where it’s at, in my opinion. ---
**Author:** ![suranyi](https://avatars.discourse-cdn.com/v4/letter/s/e36b37/32.png) [@suranyi](https://boards.straightdope.com/u/suranyi)\ **Post date:** [October 5, 2013, 12:50am UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/8 "2013-10-05T00:50:17Z")
This is yet another example of ideology trumping people’s well-being, which, as I’ve said on this message board recently, is something I despise. ---
**Author:** ![John\_Mace](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/john_mace/32/185_2.png) [@John\_Mace](https://boards.straightdope.com/u/John_Mace)\ **Post date:** [October 5, 2013, 1:08am UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/9 "2013-10-05T01:08:37Z")
> [@suranyi](#): > > This is yet another example of ideology trumping people’s well-being, which, as I’ve said on this message board recently, is something I despise. Wow. That make you ebetter than other people. Or something. > [@bump](#): > > ``` > I think it's entirely legitimate for states to question and even refuse Federal programs and mandates that are not completely funded by the Federal government in perpetuity. > > ``` > > Why should the states agree to even pick up 10% of the tab? It’s not _their_ program, but the Federal Government’s, after all. > > Mind you, I’m all in favor of single-payer universal healthcare, and even in favor of a specific tax levied to fund it. But Obamacare ain’t where it’s at, in my opinion. Exactly. States are sovereign entities and should and be able to set up their services as the people in that state desire. ---
**Author:** ![brickbacon](https://avatars.discourse-cdn.com/v4/letter/b/898d66/32.png) [@brickbacon](https://boards.straightdope.com/u/brickbacon)\ **Post date:** [October 5, 2013, 1:30am UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/10 "2013-10-05T01:30:32Z")
> [@bump](#): > > I think it’s entirely legitimate for states to question and even refuse Federal programs and mandates that are not completely funded by the Federal government in perpetuity. > > Why should the states agree to even pick up 10% of the tab? It’s not _their_ program, but the Federal Government’s, after all. Well, the PEOPLE are residents of the state as well as citizens of the US. More importantly, states are already directly and indirectly paying for not covering these people. These people still get sick and go to hospitals. They rack up bills they can’t pay, they make less money because they need to take time off work, and they pass those costs on to healthcare providers, the state, and people who are insured. Those insured people see their premiums rise, and their wage increases eaten up by health case cost increases. In short, it’s entirely likely foregoing medicaid expansion will [cost](http://www.huffingtonpost.com/2013/06/03/medicaid-expansion_n_3367301.html) these states money. That said, I am sure many more states will opt in over the next 2 years or so because the reality is that hospitals, who bear most of the brunt for uninsured patients, will see reductions in some of their Medicare reimbursement rates, and will be forced to deliver higher quality under the threat of financial consequences for failing to do so. They have a huge incentive, in the form of billions of dollars, to make sure that the people opposing this expansion have a change of heart. ---
**Author:** ![Der\_Trihs](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/der_trihs/32/233_2.png) [@Der\_Trihs](https://boards.straightdope.com/u/Der_Trihs)\ **Post date:** [October 5, 2013, 1:49am UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/11 "2013-10-05T01:49:27Z")
> [@suranyi](#): > > This is yet another example of ideology trumping people’s well-being, which, as I’ve said on this message board recently, is something I despise. > [@John\_Mace](#): > > Wow. That make you ebetter than other people. Being better than these Tea Party, let-the-poor-die fanatics isn’t much of a challenge. ---
**Author:** ![adaher](https://avatars.discourse-cdn.com/v4/letter/a/dec6dc/32.png) [@adaher](https://boards.straightdope.com/u/adaher)\ **Post date:** [October 5, 2013, 4:17am UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/12 "2013-10-05T04:17:13Z")
The federal government picks up most of the tab, but not all of it after a few years, and states are already buckling under Medicaid costs. Since most states require a balanced budget, any state that took the Medicaid expansion would have to raise taxes as soon as the feds stopped paying 100% of the cost. As for your other question, about highway funds and the 55mph speed limit, the standard the court used was whether states could plausibly turn down the money. If they can’t, then it’s “commandeering”, which is illegal for the federal government to do. Plus states have received Medicaid funding for decades now. The feds can’t take something the states depend on and use it to bend states to their will. It would essentially end state sovereignty had the court allowed it. ---
**Author:** ![usedtobe](https://avatars.discourse-cdn.com/v4/letter/u/ec9cab/32.png) [@usedtobe](https://boards.straightdope.com/u/usedtobe)\ **Post date:** [October 5, 2013, 5:18am UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/13 "2013-10-05T05:18:10Z")
> [@John\_Mace](#): > > … States are sovereign entities and should and be able to set up their services as the people in that state desire. And now adaher adds: > [@adaher](#): > > … > "The feds can’t take something the states depend on and use it to bend states to their will. It would essentially end state sovereignty had the court allowed it. " Wasn’t there a discussion (ca 186something) about where sovereignty lies in the US of A? I think some folks thought that, as sovereign entities, the States were free to leave one country and join another - wasn’t that the issue? Or was it the God-given right to own “those people” and treat them as you saw fit? 150 years later, and some still haven’t gotten it. STATES ARE NOT SOVEREIGN! I do wish they hadn’t been so stupid as to attack the US - maybe, just maybe, they could have left and we wouldn’t have a bunch of ignorant hillbillies to tolerate ---
**Author:** ![adaher](https://avatars.discourse-cdn.com/v4/letter/a/dec6dc/32.png) [@adaher](https://boards.straightdope.com/u/adaher)\ **Post date:** [October 5, 2013, 5:29am UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/14 "2013-10-05T05:29:58Z")
States are actually sovereign, but they surrendered SOME of their sovereignty to a federal government. A federal government which exists at the pleasure of the states. I don’t understand why there are still arguments about this concept after umpteen Supreme Court decisions upholding the sovereignty of the states. Most recently the ACA decision. ---
**Author:** ![adaher](https://avatars.discourse-cdn.com/v4/letter/a/dec6dc/32.png) [@adaher](https://boards.straightdope.com/u/adaher)\ **Post date:** [October 5, 2013, 5:42am UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/15 "2013-10-05T05:42:12Z")
Actually, usedtobe, let me backtrack a bit and admit that you’re right in one sense: states are not sovereign in that except for Texas they’ve never been independent nations on their own, and they cannot leave the union on their own. The sovereignty that they do have, which is substantial, is that they formed a federal government and delegated certain powers to it, powers which can be taken away from the federal government at any time if enough states wish it. The reverse is not true: the federal government cannot take away state powers and has no legal mechanism to do so. ---
**Author:** ![Damuri\_Ajashi](https://avatars.discourse-cdn.com/v4/letter/d/898d66/32.png) [@Damuri\_Ajashi](https://boards.straightdope.com/u/Damuri_Ajashi)\ **Post date:** [October 5, 2013, 6:06am UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/16 "2013-10-05T06:06:21Z")
> [@John\_Mace](#): > > Exactly. States are sovereign entities and should and be able to set up their services as the people in that state desire. Of course but it sure looks like they are passing up a really good deal for their constituents in order to thumb their noses at Obama. Doesn’t it look that way to you? ---
**Author:** ![adaher](https://avatars.discourse-cdn.com/v4/letter/a/dec6dc/32.png) [@adaher](https://boards.straightdope.com/u/adaher)\ **Post date:** [October 5, 2013, 7:44am UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/17 "2013-10-05T07:44:29Z")
What percentage are the feds paying? 90%? and can’t that be changed at any time by simple statute? Would the states be able to abandon the program then? This has all the makings of what drug dealers do. ---
**Author:** ![Lobohan](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/lobohan/32/79_2.png) [@Lobohan](https://boards.straightdope.com/u/Lobohan)\ **Post date:** [October 5, 2013, 8:43am UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/18 "2013-10-05T08:43:22Z")
> [@adaher](#): > > What percentage are the feds paying? 90%? and can’t that be changed at any time by simple statute? Would the states be able to abandon the program then? > > This has all the makings of what drug dealers do. Paranoid nonsense. Any law can be changed. Social security could be repealed if enough people vote for Tea Party candidates. ---
**Author:** ![adaher](https://avatars.discourse-cdn.com/v4/letter/a/dec6dc/32.png) [@adaher](https://boards.straightdope.com/u/adaher)\ **Post date:** [October 5, 2013, 8:58am UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/19 "2013-10-05T08:58:29Z")
That’s a bit harder to do. Making states take on more unfunded mandates is a longtime Washington tradition. If you’re saying that DC would never try to save money by making the states pay more of the freight, then I don’t buy it, and I don’t think the GOP governors do either. It’s a trap, and nothing about DC’s behavior should make them trust them. ---
**Author:** ![Broomstick](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/broomstick/32/246_2.png) [@Broomstick](https://boards.straightdope.com/u/Broomstick)\ **Post date:** [October 5, 2013, 9:43am UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/20 "2013-10-05T09:43:29Z")
> [@adaher](#): > > Actually, usedtobe, let me backtrack a bit and admit that you’re right in one sense: states are not sovereign in that except for Texas they’ve never been independent nations on their own, and they cannot leave the union on their own. [Nitpick] Hawaii was also a sovereign state for centuries prior to joining the US first as a territory and then as a state [/nitpick] [Next page](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384.md?page=2)