# 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:** 2
**Author:** ![Cheesesteak](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/cheesesteak/32/3694_2.png) [@Cheesesteak](https://boards.straightdope.com/u/Cheesesteak)\ **Post date:** [October 5, 2013, 10:55am UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/21 "2013-10-05T10:55:30Z")
> [@John\_Stamos\_Left\_Ear](#): > > 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? Why does there have to be a reason that makes sense? Anyway, I fully support all of these Republican headed states contributing their constituents Federal tax dollars to the expansion of Medicaid in my state. Thank you for the gift, 'tis much appreciated. ---
**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, 11:46am UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/22 "2013-10-05T11:46:10Z")
Ah, you want us to fall for the prisoners’ dilemma. More evidence that illegal coercion was intended. ---
**Author:** ![Fear\_Itself](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/fear_itself/32/19637_2.png) [@Fear\_Itself](https://boards.straightdope.com/u/Fear_Itself)\ **Post date:** [October 5, 2013, 11:55am UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/23 "2013-10-05T11:55:41Z")
> [@adaher](#): > > Ah, you want us to fall for the prisoners’ dilemma. More evidence that illegal coercion was intended. Coercion is not illegal. ---
**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, 12:50pm UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/24 "2013-10-05T12:50:37Z")
It is when the federal government tries to do it to the states. ---
**Author:** ![Fear\_Itself](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/fear_itself/32/19637_2.png) [@Fear\_Itself](https://boards.straightdope.com/u/Fear_Itself)\ **Post date:** [October 5, 2013, 12:53pm UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/25 "2013-10-05T12:53:32Z")
No it isn’t. Because if it were illegal, the states could appeal it to the Supreme Court, which is the final arbiter of what is or isn’t illegal. It isn’t illegal just because you say so. ---
**Author:** ![BrokenBriton](https://avatars.discourse-cdn.com/v4/letter/b/4bbf92/32.png) [@BrokenBriton](https://boards.straightdope.com/u/BrokenBriton)\ **Post date:** [October 5, 2013, 1:07pm UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/26 "2013-10-05T13:07:26Z")
> [@John\_Stamos\_Left\_Ear](#): > > W > > 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/):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: Follow the money - look at how many campaign contributors have ‘health’ in their title: [http://www.followthemoney.org/database/uniquecandidate.phtml?uc=132328](http://www.followthemoney.org/database/uniquecandidate.phtml?uc=132328) ---
**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, 1:13pm UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/27 "2013-10-05T13:13:50Z")
> [@Fear\_Itself](#): > > No it isn’t. Because if it were illegal, the states could appeal it to the Supreme Court, which is the final arbiter of what is or isn’t illegal. It isn’t illegal just because you say so. Um, the states did, and the federal government lost the Medicaid expansion case 7-2. ---
**Author:** ![Wesley\_Clark](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/wesley_clark/32/20581_2.png) [@Wesley\_Clark](https://boards.straightdope.com/u/Wesley_Clark)\ **Post date:** [October 5, 2013, 2:01pm UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/28 "2013-10-05T14:01:57Z")
Because darkie McPresident supported it. There may be some fears that down the line the states will have to pay more of the medicaid share but a lot is just partisan spite. Plus a lot of conservatives have ideological objections to both social programs for the poor as well as government healthcare, and medicaid is both. ---
**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, 2:11pm UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/29 "2013-10-05T14:11:53Z")
> [@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. Really? If Medicaid is such a bad deal, then why does every state accept the money now? They are not required to have it at all, yet all of them have opted to adopt it. Currently, they only get reimbursed by the federal government 57% of costs on average. Why would they reject an expansion covered at 100% initially, then 90% later on when they currently accept a deal that only nets them 57%? Especially given that changing those reimbursement rates would require representatives of their own state (and similarly situated states) to vote against their own interests? How does rejecting this make sense to you at all? This is doubly stupid because of two other hugely important factors: hospital Medicaid reimbursment rates will deline as part of the ACA, which means revenues will fall while costs increase, and because states ALREADY PAY INDIRECTLY FOR THE UNINSURED. Uninsured people generally don’t have the curtousy to die in the street. They use expensive resoucres they cannot afford. Not only does that hurt every citizen in the state who has insurance, but it also means the states missing out on LOTS of tax revenue. Obamacare may make a state’s finances look different, but it probably won’t make them look worse. Even if these states needed to raise taxes to cover costs later on, the system should be more efficient as a whole. But like I said, within 5 years, the vast majority of these states will expand because the pressure from health care providers will be too great. No one is gonna leave tens of billions of dollars on the table on the off chance that it will be slightly less than that later on. ---
**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 5, 2013, 9:25pm UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/30 "2013-10-05T21:25:33Z")
> [@John\_Stamos\_Left\_Ear](#): > > Is there evidence that they have reason to worry? Has the USA told states they would get funds for something and then reneged? Recently? I am asking this a second time. ---
**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 5, 2013, 10:47pm UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/31 "2013-10-05T22:47:16Z")
> [@adaher](#): > > Making states take on more unfunded mandates is a longtime Washington tradition. Except that Medicaid is not an Unfunded Mandate and never has been one. Duties that arise from conditions of federal assistance or that are tied to participating in voluntary federal programs generally are not considered mandates. And thanks to the Unfunded Mandates Reform Act, signed into law by Bill Clinton in 1995, it would be exceedingly difficult to make any changes. Anything else, or just paranoid as usual? Well, I know the answer to that one. So do the Republican governors have anything else, or are \*they \*just paranoid too? (Or, um, being dishonest about their reasons.) ---
**Author:** ![Mr\_Quatro](https://avatars.discourse-cdn.com/v4/letter/m/bc8723/32.png) [@Mr\_Quatro](https://boards.straightdope.com/u/Mr_Quatro)\ **Post date:** [October 6, 2013, 12:03am UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/32 "2013-10-06T00:03:47Z")
Your question reminds me of the Real ID Act of 2005 that is still being resisted by a handful of states. Needs it’s own thread, but still worth bringing up as to how stubborn states can be:[Real ID deadlines looms | Homeland Security Newswire](http://www.homelandsecuritynewswire.com/dr20120131-real-id-deadlines-looms) > [@](#): > > The federal deadline for states to notify DHS that they have “substantially compliant” with the rules is 15 January 2013. The REAL ID Act of 2005 prohibits federal agencies from accepting non-compliant driver’s licenses “for identification purposes” after the deadline. > [@](#): > > The DHS secretary has the authority to provide extensions to individual states, as long as the state has provided a self-certification that it intends to comply. Most states have sent letters to DHS stating that they will comply.\*\* A handful of states, however, have indicated that they will not comply because their legislatures have enacted laws that prohibit them from complying \*\*with the REAL ID Act. ---
**Author:** ![usedtobe](https://avatars.discourse-cdn.com/v4/letter/u/ec9cab/32.png) [@usedtobe](https://boards.straightdope.com/u/usedtobe)\ **Post date:** [October 6, 2013, 3:01am UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/33 "2013-10-06T03:01:35Z")
> [@BrokenBriton](#): > > Follow the money - look at how many campaign contributors have ‘health’ in their title: > > [http://www.followthemoney.org/database/uniquecandidate.phtml?uc=132328](http://www.followthemoney.org/database/uniquecandidate.phtml?uc=132328) Good Lord, that is a Who’s Who of sleazy and barely-legal players in the For-Profit “healthcare” industry. And I’m not in the business - if I recognize a name, it is because they made the news - and none of these were written up for being nice or fair or legal. ---
**Author:** ![adaher](https://avatars.discourse-cdn.com/v4/letter/a/dec6dc/32.png) [@adaher](https://boards.straightdope.com/u/adaher)\ **Post date:** [October 6, 2013, 5:39am UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/34 "2013-10-06T05:39:56Z")
And those sleazy players don’t want the government to give them money to care for people? ---
**Author:** ![elucidator](https://avatars.discourse-cdn.com/v4/letter/e/8edcca/32.png) [@elucidator](https://boards.straightdope.com/u/elucidator)\ **Post date:** [October 6, 2013, 5:49am UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/35 "2013-10-06T05:49:38Z")
Oh, they are perfectly willing to let the government give them money! ---
**Author:** ![Mdcastle](https://avatars.discourse-cdn.com/v4/letter/m/958977/32.png) [@Mdcastle](https://boards.straightdope.com/u/Mdcastle)\ **Post date:** [October 6, 2013, 2:43pm UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/36 "2013-10-06T14:43:35Z")
Medicaid pays providers a pittance compared to commercial providers, or even Medicare. (I’ve worked with claims for all three, and providers that can sometimes refuse Medicaid patients). If some of the people find a way to get Medicare or a commercial policy (including Obamacare) rather than an expanded Medicaid than the hospitals and insurance companies come out ahead. As for the original question, maybe people are thinking about this too much. Maybe Republicans just think of it as income redistribution so are ideologically opposed to it whether it’s a “good deal” or not. ---
**Author:** ![elucidator](https://avatars.discourse-cdn.com/v4/letter/e/8edcca/32.png) [@elucidator](https://boards.straightdope.com/u/elucidator)\ **Post date:** [October 6, 2013, 5:02pm UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/37 "2013-10-06T17:02:22Z")
Let’s be fair about this, comrades. Come the Revolution, and we put them up to the Wall, let them take their money with them. ---
**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 7, 2013, 4:57am UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/38 "2013-10-07T04:57:21Z")
> [@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. Considering that the state can then drop the extra coverage, you’re saying that states will have political problems doing so because it will be popular…right? That all this extra medical care is like crystal meth, once they get hooked on it they won’t want to give it up?:dubious: > [@adaher](#): > > That’s a bit harder to do. Making states take on more unfunded mandates is a longtime Washington tradition. Its unconstitutional and I don’t think you can point to very many cases where states were forced to take on unfunded mandates. > [@](#): > > 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. Thats the thing about our federal government… they is us. > [@adaher](#): > > Ah, you want us to fall for the prisoners’ dilemma. More evidence that illegal coercion was intended. The prisoner’s dilemma posits a negative result for the non-cooperating prisoner. What is the negative result here (other than less medicaid, which seems to be the result you want). ---
**Author:** ![BigT](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/bigt/32/12044_2.png) [@BigT](https://boards.straightdope.com/u/BigT)\ **Post date:** [October 9, 2013, 4:30am UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/39 "2013-10-09T04:30:52Z")
> [@Mdcastle](#): > > As for the original question, maybe people are thinking about this too much. Maybe Republicans just think of it as income redistribution so are ideologically opposed to it whether it’s a “good deal” or not. Again, if so, why do they enact Medicaid at all? It’s forcing them to have to do all the redistribution themselves instead of getting more money from the feds. Heck, are the feds even required to keep paying if these states keep with their track record of reducing coverage for the people who already have it? ---
**Author:** ![puddleglum](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/puddleglum/32/137_2.png) [@puddleglum](https://boards.straightdope.com/u/puddleglum)\ **Post date:** [October 9, 2013, 3:49pm UTC](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384/40 "2013-10-09T15:49:41Z")
> [@BigT](#): > > Again, if so, why do they enact Medicaid at all? It’s forcing them to have to do all the redistribution themselves instead of getting more money from the feds. > > Heck, are the feds even required to keep paying if these states keep with their track record of reducing coverage for the people who already have it? The thing with programs that give away money is that once they are started they are hard to do away with. For example tobacco subsidies, the government paid 188 million dollars in subsidies to farmers growing tobacco in 2012. The Senate just voted this May to keep paying the subsidies even though the same government is spending about 50 million dollars a year for ads trying to keep people from smoking. In WW2 uniforms were made from wool and the army had problems securing enough to keep up with demand. So congress enacted wool and mohair subsidies in 1954. They are still going on to the tune of 20 million a year even though the military uses mostly synthetic fibers now. So a responsible governor takes into account that a program will be hard to end and looks down the road for the consequences. The average state pays 16% of its budget for Medicaid and opting into the expansion will raise costs an estimated 2.8% for the next eight years and more after that. Medicaid costs have rised over 7% a year over the last decade while state tax revenues have risen about 3.5%. Thus Medicaid is set to take up more and more of state budgets in the future. Given budget realities states need to look at ways to decrease amounts spent of Medicaid instead signing up for more spending. [Previous page](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384.md?page=1) [Next page](https://boards.straightdope.com/t/why-are-so-many-states-not-taking-the-medicaid-expansion/670384.md?page=3)