The decision of some states not to expand Medicaid coverage to some of its neediest residents, should raise serious questions as to the role of government in serving its people. The states, 25 in all, mainly those with Republican governors or Republican-controlled legislatures, have so far refused the proposed extension , in part because of concerns about long-term costs or government outreach.
Under the Affordable Care Act (ACA), states are required to provide subsidies for those who earn income up to 400% of the federal poverty level (FPL). In addition, the ACA recommends that Medicaid coverage (health insurance for those below the poverty line), should be expanded to those up to 133% of the poverty line. However, since the Supreme Court ruled that such expansion cannot be mandatory, but rather is up to the discretion of the states, approximately half the states opted out. It so happens that more than half of all people without health insurance live in states that are not planning to expand Medicaid.
What is most concerning is that in some states, Kansas is a case in point, that while children under the poverty line are covered under Medicaid, low income families with children are only covered if their income averages something like 28% of Medicaid ( $470 for four individuals). In Mississippi (another state that refuses to expand coverage) the threshold is $443 net income (or $819 gross). So if you are moderately poor, you will get subsidies, if you are poor, you will be eligible for Medicaid, but if you are really, really poor – well then, it is just too bad. I do not envy the state employee in Kansas, Mississippi, Texas or any of these states, who has to explain to the mother who can barely afford to feed herself or her children, that even though there is a federal law in place to help her, her state refuses. Storm the governor’s mansion, I say, or the state senate – you choose.
The claim that refusal to extend coverage is based upon cost consideration cannot have sound economic basis either. Although I do not have the numbers to prove it, I will venture out and say that I am hard-pressed to believe that providing adults with health insurance is more expensive than paying for their, sometime frequent, visits to the emergency room and the long-term consequence of lack of preventive care. Just a thought..
Finally, we need to frame this issue as a part of a larger discussion of how we view healthcare. If we view it as a privilege then this is a non-conversation. But if we view healthcare as a right, something that we, as citizens, are entitled to, then we are failing. We should view health much like we view food- something we should be able to afford given our entitlement bundle. A person should be able to command sufficient bundle through the use of production possibilities, trade opportunities, and entitlements vis-à-vis the state so as to allow for good nutrition and health. Lack of nourishment and ill-health then, reflect an entitlement failure within the context of Sen’s Entitlement Approach. Most importantly for our discussion, is that the implication for ill health resulting from insufficient government entitlements is the result of: “inadequate public health provisions and nutritional support, deficiency of social security arrangements, and the absence of social responsibility and of caring governance” (Sen). Something to think about…