Thursday, February 7, 2013

At The Core of Obamacare Future: Trust in Government
Trust, once gone, never returns.

February 7, 2013-  Obamacare’s future rests on trust in government.
The Accountable Care Act passed in March 2010 without a single Republican vote,  under questionable parliamentary tactics, in the dead of night, with Medicaid bribes to three wavering Democratic senators,  without giving opponents  or advocates  time  to read the 2700 page bill.
That act of political arrogance and chicanery  violated  trust in government. It poisoned the political well for the Obama administration. It may have been a noble deed, but it was done ignobly.
At the core of Obamacare, indeed, the very reason for its existence, is expanding of Medicaid eligibility to all adults with family incomes at or below 138% of the federal poverty level. Officially, this amounts to 30 million new Medicaid recipients, but it may be closer to 40 million, even 50 million, if one counts those likely to be dropped by employers who claim Obamacare provisions render  coverage unaffordable.   Obamacare affects all of us, 314 million Americans, in one way or another.
Unleashing A Tiger Called Distrust
When the Supreme Court ruled last summer  that the ACA was constitutional but Medicaid expansion was optional for the states, the Court  let a Tiger called Distrust  out of the cage.  Distrust, once on the loose,  ranged far and wide to State capitols in the South, Midwest, Southwest, and West.
To some extent,   Distrust stalks  Republicans governors, who must bear the budget brunt of Medicare expansion,   hospitals and physicians, and seniors, who must swallow the cuts necessary to finance Medicaid expansion. 
Hanging in the Balance
The  fate of the ACA hangs in the balance at the level of State Governors and legislators..
If you doubt what I say, I invite you to read “U.S. Governors and The Medicaid Expansion, “ in today’s New England Journal of Medicine from two authors at the Department of Health Policy and Management at the Harvard School of Public Health.
According to the article, the ACA and the Supreme Court’s Medicaid June 2012  opt-out decision divided the States into those who trust the federal government and those who do not.
Trusting,  Distrusting, and Undecided States
The states fall into these categories:
·         20 Trusting States with Democratic Governors and one with a Republican Governors who approved Medicaid expansion.

·         13 Distrusting States with Republican Governors who opposed Medicaid expansion.

·         17 Undecided States not knowing whom to Trust, 2 with Democratic Governors  17 with Republican Governors, who were undecided.
Themes of Trust and Distrust
Among the themes of those opposing ACA expansion, those supporting it, and those undecided were these.
·         Supporting States:  Medicaid will cover the uninsured, expansion bolsters the State’s preexisting efforts in health reform, will save State and taxpayers money, will improve people’s health.

·         Opposing States  will increase State budgets devoted to Medicare, will deprive State’s flexibility and freedom from federal oversight, federal government will renege on funding, States would have to raise taxes to pay for it,   States need more information,  Medicaid is “broken,” entitlement program, promotes dependency.

·         Undecided States: need more information, concerns about increasing state budgets,  States need more flexibility and freedom, may require States to cut funding for education and other programs, waiting to see what election portends..
Expressions of Distrust

Republican governors  colorfully expressed  their distrust.  Governor Mike Pence of Indiana compared the expansion to “The classic gift of a baby elephant” with the feds saying, “We’ll pay for the hay – at least for the first few years.” Governor  Rick Perry of Texas remarked “ Adding uninsured Texans to Medicaid, is not unlike adding a thousand people to the Titanic.” Governor Rick Scott of Florida was more circumspect, “The election is over.  President Obama won. I’m responsible for the families of Florida…If I can get to yes, I want to get to yes.”
However one slices Obamacare, whether one supports it or opposes it,  it all comes down to trust  or distrust in the federal government.
Tweet:  Obamacare’s future hangs on whether States trust government and Obamacare to deliver on its promises to support Medicaid expansion.

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