The narrative of the Medicaid part of the decision has centered around the court's one rebuke to the government: that the federal government could not threaten existing Medicaid funding to states that refuse to participate in the extended program. As I pointed out in my previous piece, while the Administration claimed that it had such powers under the Affordable Care Act, however, it never planned to use it.Well, it turns out that the Republicans are running out of excuses to turn down free money faster than you can say 'hospital lobby.' Republican governors who were vehemently opposed to Obamacare are now quickly falling in line, reversing their positions about not accepting Obamcare money for Medicaid. New Jersey governor Chris Christie became the latest caver, following the flip flop of the decade from Gov. Rick Scott of Florida, the original plaintiff challenging Obamacare.
And that's because it doesn't need to. The expansion of Medicaid - at 100% funding by the federal government for the first three years (and 90% thereafter) - will be insanely difficult for even the reddest states to turn down. For the first three years, it costs them nothing - just what will be their excuse not to get free money?
Sure, it still leaves the likes of Scott Walker of Wisconsin and Rick Perry of Texas as Republican governors who are still vowing to refuse the money. But the tide is shifting in favor of high profile Republican governors publicly surrendering the battle on Obamacare. And they are the smart ones. They know that they don't want to fight a re-election fight in 2014 over this issue, especially given that in 2014, they can no longer run against a caricature of Obamacare as the exchanges open and people begin to start getting covered. In his announcement, Christie sent a message that should be obvious to anyone with a half a brain:
“Let me be clear, refusing these federal dollars does not mean that they won’t be spent,” he said. “It just means that they will be used to expand health care access in New York, Connecticut, Ohio or somewhere else.I wonder if I had said something like this before. Ahem... back to my piece on the Court decision:
Should a state turn that money down, that money could move to other states, which would make providers and manufacturers go after business there. I doubt very much that Republican governors want to be exposed for directly driving medical business out of their states.And that is the stick that is going to be working its way even if at the beginning some states choose to stay out of the Medicaid expansion. If Texas doesn't want the money, frankly, we in California will be glad to take it and expand Medicaid even beyond what's required in the Affordable Care Act, as the law allows us to. We will be more than happy to make sure that our hospitals don't have to provide for uncompensated care while hospitals in Texas get stuck doing that exact same thing. One has to wonder what would happen if the hospital industry pulls its support from Rick Perry. Some big counties within Texas aren't all that cool about giving up on this big chunk of federal cash, either. Perry may not like it, but some Texas Democrats may decide to take it straight to the ballot.
Rick Perry may not be facing much of a Democratic challenge to his governor's mansion. But that doesn't mean that he can avoid the most pervasive influence in American politics: money.
There will be other about faces. The Medicaid expansion to everyone under 133% of the federal poverty level has always been the real public option in the Affordable Care Act, and Republican states run the risk of having the money they won't use for Medicaid being used in other states to create more expanded public coverage, better health outcomes, and lower costs for both patients and providers. This weekend, I was at a health care innovators' challenge at Stanford University. You know what I learned? Top employers are competing for top employees through superior health care and wellness programs. States have that same competition for talent, as well as for top employers.
Success is very hard to argue with. That's what the Republicans were always afraid of when it came to ObamaCare - that it would succeed. The Medicaid expansion is a crucial component of that success, and Republicans who stand in its way will only hurt their party and their constituents - without being able to actually stop it.