Medicaid Matters: Expansion Debate a (Lost?) Opportunity

By Marcia Kinsey and Elaine Mejia

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Medicaid is the health insurance provider for millions of Americans, particularly children whose parents earn low wages, pregnant women, disabled adults and low-income seniors who have long-term care needs. This 48-year-old program has been in the spotlight and under the microscope since 2009, when the Affordable Care Act used it as the primary vehicle for expanding health insurance coverage to 17 million of the estimated 32 million uninsured Americans.

This year is the deadline for state governments, which operate the program within their borders, to decide whether they will participate in the expansion. The federal government will pay the full cost of Medicaid expansion for the first three years and 90% of the cost after that.

But some Republican governors are determined to prevent Medicaid expansion in their states. Governor Rick Perry of Texas, for example, stands in staunch resistance to expansion, in spite of the fact Texas has more than its fair share of folks likely to qualify under the new rules. In fact, Perry’s home state boasts the highest rate of uninsured – 1 in 4 residents – of any state in the nation.

Perry, like so many opponents, is lobbing familiar memes like “socialized medicine” and claims that Washington politicians are forcing a “one-size-fits-all” solution onto ostensibly unique and independent states. Lately though, he’s argued that it’s all about the money – as in Texas can’t trust Washington politicians to keep their promises to pay the bills.

Perry is attempting to counter one of the central arguments of the expansion proponents – that the expansion is a no-brainer because it won’t cost state residents a dime. Proponents, by and large, seem to have decided that this line of reasoning is the surest path to victory.

But if proponents are mainly arguing that expansion should go forward because it’s free and opponents are saying that there is no such thing as a free lunch, then who’s talking about why Medicaid matters? The answer, unfortunately, is almost no one.

It’s time to get to the heart of the matter—that Medicaid serves a fundamental public purpose that benefits all Americans regardless of whether they currently or potentially stand to receive coverage. Advocates in favor of expansion need to tell a bigger story about why public involvement and funding of health care for all strengthens our democracy and our economy and is worthy of broad public support, including financial support.

We have seen some examples of leaders talking about why Medicaid and public funding for health care matter in a broader sense, such as in this infographic from Washington and this video from Arkansas. But such messages have been few and far between.

When we attempt to bolster support for Medicaid and other programs with arguments of cost savings, we actually reinforce the dominant paradigm – that public functions are only worthwhile if they save us money – we undermine our other efforts to help people recognize the value of the public sector as a force for the common good. In doing so, we make future public debates much more difficult to win.

With the Medicaid debate we actually have the public with us. Polls show that many Americans have a direct connection to the program and majorities strongly support its continuation and expansion. Our challenge is to help turn that latent support into action by connecting the dots between the current debate over expansion and the widespread ripple effects of the outcome.

After a decade of work in states around the country, Public Works has come to understand that public policy debates that focus almost solely on money and facts constrain our national imagination. Whether it’s one school district’s bond referendum or a national move to expand Medicaid, as long as the debate is only about costs or savings to taxpayers, voters are never called on to be citizens, to consider what role their vote or their advocacy can play in making their community, their state, or their nation a better place for all of us.

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