Mixed Medicaid Metaphors

The greatest thing in style is to have command of the metaphor.

Aristotle(  384-322 B.C.), Poetics

July 14, 2012 -  I wish I could say I have command of the metaphor,  but I do not.  Too often I mix my metaphors.

But I know a good metaphor when I see one.  In a July 12 Wall Street Journal editorial,  “Medicaid Moment of Truth,” the writer ended with this metaphor, “The Governors would be crazy to strap themselves to this entitlement bomb.”

The bomb he was referring to the Affordable Care proposal that the federal government foot 100% of the bill for 16 million to 20 million new Medicaid patients in 2014, then dropping to 90% after three years. 

On the surface, this looks like a exceedingly  generous proposal – “free” government money to cover “new” Medicaid patients for three years   To Obamacare aficionados,  this is an offer the states cannot afford to refuse.

But already,  because of the Supreme Court ruling that states can opt out of federal Medicaid expansion,   the governors of up to 15 states, most notably Florida and Texas,  are declaring they will refuse to accept  federal money for Medicaid expansion in 2014.  Taken together,  these states contain 40% of potentially new Medicaid recipients.

Are these governors crazy?  To use a few overused metaphors: Are they kicking a gift horse in the mouth?  Are they refusing to follow the Piper when  the Piper is calling the tune?   No, say the governors, the devil is in the details.

 The details are these.

·         After three years,   the federal government may be strapped for cash, ever deeper in debt,  and may well renege on its promises.

·         The current Medicare load gobbles up an average of 25% of state budgets, and the cost will jump 12% in 2012,  on current Medicaid patients, an increase the states can ill afford

·         There are currently 9 million eligible Medicaid patients in the states who have not even signed up for benefits, and because of slashes in doctor reimbursement,  there aren't enough doctors to care for these patients, much less 16 million to 20 million more in 2014.

·         By law, most  states, unlike Washington, have to meet their budgets, and cannot print money to cover cost overruns.

Resistant governors argue that turning over complete control of state Medicaid programs  to the feds would simply make states an appendage and passive tool of central planners, stripping the states of the flexibility inherent in block Medicaid grants, which allow states to design and control their own Medicaid destinies  and to allow monies to go to education, roads,  other social benefits, including pension benefits.

Federal largess,  in short, comes with strings attached.   Over- attachment to government can be a dangerous game. It may represent a transfer of power and a violation of the sovereignty of the states.  In the end, it depends on who is left holding the short string.  There is more than one string to every bow.

Tweet:  Growing numbers of state Governors are taking up the  Supreme Court on its decision allowing them to opt out of Medicaid expansion