“Impossible to Argue Against” – The Significant Change in State Debates over Accepting Medicaid Funding

Last week I noted how two very unusual editorials at major newspapers in Tennessee and Florida indicated what I called a “debate turning point” on the Medicaid expansion funding issue. Since then there is more evidence of this turning point in both of these states – which haven’t yet accepted the federal money for expanded coverage – and, more clearly, in Montana where a bill on Medicaid expansion is expected to be signed by the Governor shortly. There are indications this change in the debate could spread to other states as well.

 What’s Going On?

Over twenty years of being involved in public policy debates around health care and children’s issues, I can think of a very few instances similar to what is happening now around the Medicaid expansion debate in Tennessee and Florida. Stefanie Murray, the executive editor of The Tennessean newspaper, most clearly articulated the change. In today’s explanation as to why her paper decided to devote its entire front page on April 12 to a strongly-worded editorial and call for action on the Tennessee Medicaid plan, Insure Tennessee, Murray wrote:

 [T]here are some topics that are nearly impossible to argue against — sexual assault, illiteracy, and hunger come to mind. We think access to basic health care belongs on the list, which is what Insure Tennessee would bring to thousands of fellow Tennessee residents.

 The key here is Murray’s assertion that access to basic health care through acceptance of the federal funding for Insure Tennessee is “nearly impossible to argue against.” You can see the same feeling expressed in the Tampa Bay Times’ full page editorial calling legislators blocking expansion an “immoral minority” in three inch high type. Or – the most recent example this week – a comprehensive and exhaustive series of interrelated reporting on Medicaid in the Miami Herald where Florida residents denied Medicaid are forced to choose “between dinner and a medical test.” The latest expose from Tennessee – that James Davy Crockett (yes, a direct descendant) is uninsured and caught in the Medicaid coverage gap is simply icing on this cake.

The clear feeling from these respected news outlets is not simply that they have taken a side on a particular policy issue. Rather it is that extending basic health coverage with the federal Medicaid funding is an argument where Medicaid expansion has the moral, policy and practical high ground – and a high ground that is pretty unassailable. Thus, not only will they editorialize, but they will advocate asking readers to contact legislators and push for more health coverage. They won’t just report a few stories before the issue fades away – they will continue to report again and again on the human, economic and social costs of refusing expansion. In short they will take a more active and higher-profile role than they do on most issues.

And it isn’t just the news outlets where you can see this change. In a little-noticed action last week, the Florida Philanthropic Network, a very diverse range of Florida grantmakers with over $6.5 billion in assets, also issued a statement saying “[e]xtending healthcare coverage to more Floridians is crucial to the state’s future” and that state residents should “raise their voices on this critical issue.” This is a group that includes everyone from local community foundations to health philanthropies  – a model of a quiet, conservative and responsible philanthropic association. When a group like this feels confident enough to weigh in on an issue, it is a strong indicator of the strength of a particular position.

 Federal Government Action

The other indicator (and certainly driver as well) here of the debate change is the willingness of the federal government to more clearly articulate its position in Florida and Texas regarding each state’s continuing receipt of what were always deemed temporary funding streams of billions of federal dollars to hospitals and health clinics caring for uninsured patients. [Read my colleague Joan Alker’s crisp explanation of this issue.] Now federal officials are making clear to both states that taking advantage of the Medicaid expansion funding to actually move people into health plans is an important way to deliver coverage and must be considered in the context of this other federal funding.

A Unique Public Policy Moment?

While opposition to accepting the federal Medicaid funding is obviously not going away in any of these states, the move of the debate to the different level outlined above does make eventual action by all these states much more likely. At this level – where it is “nearly impossible to argue against” – there is a sort of snowball effect where many more influential people and institutions in each state feel comfortable entering into the call for action. Even in a state like Utah where Governor Gary Herbert’s plan to accept the federal Medicaid dollars has been delayed reports appeared stating that Herbert was planning travel to Washington with both the state’s House Speaker and Senate President to engage in further federal Medicaid discussions.  Bringing all parties to the table is a positive sign that perhaps a compromise can eventually be achieved.

Overall, the mix of factors are pushing the debate over Medicaid expansion to a different level and can be expected to exert influence beyond the “will they or won’t they” tenor of state-by-state decisions on whether or not to accept the Medicaid funding. Once an issue becomes a “must-have” – a phrase used about Medicaid by Alaska’s Governor Bill Walker last month – this means that action, while by no means certain, is more likely and will continue to be so. Delay is almost always the friend of opponents of legislative action. However, delay also can sometimes mean time for continuing education, continuing stories of people suffering from inaction and a building of involvement by normally cautious organizations and interests. Delay then turns to an advantage. Whatever happens legislatively over the next few weeks in Tennessee and Florida, the change in the Medicaid debate in those states has converted a negative into an opportunity. Montana and Utah’s possible moves forward will only contribute to this movement and, given the state’s size and political environment, it will be fascinating to see how this debate plays out in Texas. Public policy on health care for poor people has rarely gotten this much attention.

Adam Searing is an Associate Professor at the Georgetown University McCourt School of Public Policy’s Center for Children and Families.

Latest