Debate Desk
Should Every State Expand Medicaid to Cover More Adults?
Expansion covers more people with a large federal match, but it pays more for new adults than for the disabled and poor children the program was built for.
The claim
Supporters say that the federal government pays most of the cost of expansion, that coverage saves lives and reduces medical debt, and that states that decline are turning away their own tax dollars and leaving working adults without care.
The answer in three points
- The Supreme Court made expansion optional for states in NFIB v. Sebelius (2012), and that choice is for state legislatures and voters. Federalism means states can weigh the program against their budgets, priorities and other options.
- The federal match for the expansion population is higher than for traditional Medicaid beneficiaries such as disabled people and low-income children. That gives states an incentive to prioritize able-bodied adults over those the program was designed to serve.
- Medicaid is already one of the largest items in state budgets. A match that sounds generous can still leave a state with a growing share of costs, and it limits other spending on schools and roads. Work requirements and other measures can focus the benefit and encourage people toward employment.
A state that expands or declines is making a budget choice, and voters should know what it costs and what the alternatives are. Federalism lets each state weigh its own needs and learn from others.
The numbers
- The Affordable Care Act's Medicaid expansion provides a federal match of 90 percent for the expansion population, according to the Centers for Medicare and Medicaid Services.
- The Kaiser Family Foundation reports that a large majority of states, about 40 plus the District of Columbia, have adopted expansion.
- The Supreme Court held in National Federation of Independent Business v. Sebelius (2012) that Congress could not coerce states into expansion by threatening to withdraw existing Medicaid funds.
What they will say next
"Expansion states saw better health outcomes." Some studies find improvements and others find little effect on measured health. Coverage helps with access, and the program's overall value depends on what it displaces.
"Hospitals want it." Hospitals gain from more insured patients, and that interest is real. Voters must also weigh the costs to taxpayers and the care for the original groups.
"Work requirements are cruel." Many Americans believe a program for able-bodied adults can reasonably ask for work, training or service, as the 1996 welfare reform did. Properly administered, it can be a path to independence.
"Not expanding leaves a coverage gap." True, and states can address it in other ways, such as through subsidized private plans or waivers that test different designs.
States are laboratories. Citizens can ask their legislators for the full cost and the other options.
"The money is on the table and states are refusing it." The federal money is borrowed or taxed from residents of every state, including the ones that decline. A state may reasonably judge that a program that grows with a federal promise, and shifts costs to the state if the match is later reduced, carries risks that a legislature must weigh, and some did so in good faith.