JDN 2457422

As of this writing, there are still 22 of our 50 US states that have refused to expand Medicaid under the Affordable Care Act. Several other states (including Michigan) expanded Medicaid, but on an intentionally slowed timetable. The way the law was written, these people are not eligible for subsidized private insurance (because it was assumed they’d be on Medicaid!), so there are almost 3 million people without health insurance because of the refused expansions.

Why? Would expanding Medicaid on the original timetable be too arduous to accomplish? If so, explain why 13 states managed to do it on time.

Would expanding Medicaid be expensive, and put a strain on state budgets? No, the federal government will pay 90% of the cost until 2020. Some states claim that even the 10% is unbearable, but when you figure in the reduced strain on emergency rooms and public health, expanding Medicaid would most likely save state money, especially with the 90% federal funding.

To really understand why so many states are digging in their heels, I’ve made you a little table. It includes three pieces of information about each state: The first column is whether it accepted Medicaid immediately (“Yes”), accepted it with delays or conditions, or hasn’t officially accepted it yet but is negotiating to do so (“Maybe”), or refused it completely (“No”). The second column is the political party of the state governor. The third column is the majority political party of the state legislatures (“D” for Democrat, “R” for Republican, “I” for Independent, or “M” for mixed if one house has one majority and the other house has the other).

State	Medicaid?	Governor	Legislature
Alabama	No	R	R
Alaska	Maybe	I	R
Arizona	Yes	R	R
Arkansas	Maybe	R	R
California	Yes	D	D
Colorado	Yes	D	M
Connecticut	Yes	D	D
Delaware	Yes	D	D
Florida	No	R	R
Georgia	No	R	R
Hawaii	Yes	D	D
Idaho	No	R	R
Illinois	Yes	R	D
Indiana	Maybe	R	R
Iowa	Maybe	R	M
Kansas	No	R	R
Kentucky	Yes	R	M
Lousiana	Maybe	D	R
Maine	No	R	M
Maryland	Yes	R	D
Massachusetts	Yes	R	D
Michigan	Maybe	R	R
Minnesota	No	D	M
Mississippi	No	R	R
Missouri	No	D	M
Montana	Maybe	D	M
Nebraska	No	R	R
Nevada	Yes	R	R
New Hampshire	Maybe	D	R
New Jersey	Yes	R	D
New Mexico	Yes	R	M
New York	Yes	D	D
North Carolina	No	R	R
North Dakota	Yes	R	R
Ohio	Yes	R	R
Oklahoma	No	R	R
Oregon	Yes	D	D
Pennsylvania	Maybe	D	R
Rhode Island	Yes	D	D
South Carolina	No	R	R
South Dakota	Maybe	R	R
Tennessee	No	R	R
Texas	No	R	R
Utah	No	R	R
Vermont	Yes	D	D
Virginia	Maybe	D	R
Washington	Yes	D	D
West Virginia	Yes	D	R
Wisconsin	No	R	R
Wyoming	Maybe	R	R

I have taken the liberty of some color-coding.

The states highlighted in red are states that refused the Medicaid expansion which have Republican governors and Republican majorities in both legislatures; that’s Alabama, Florida, Georgia, Idaho, Kansas, Mississippi, Nebraska, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Utah, and Wisconsin.

The states highlighted in purple are states that refused the Medicaid expansion which have mixed party representation between Democrats and Republicans; that’s Maine, Minnesota, and Missouri.

And I would have highlighted in blue the states that refused the Medicaid expansion which have Democrat governors and Democrat majorities in both legislatures—but there aren’t any.

There were Republican-led states which said “Yes” (Arizona, Nevada, North Dakota, and Ohio). There were Republican-led states which said “Maybe” (Arkansas, Indiana, Michigan, South Dakota, and Wyoming).

Mixed states were across the board, some saying “Yes” (Colorado, Illinois, Kentucky, Maryland, Massachusetts, New Jersey, New Mexico, and West Virginia), some saying “Maybe” (Alaska, Iowa, Lousiana, Montana, New Hampshire, Pennsylvania, and Virginia), and a few saying “No” (Maine, Minnesota, and Missouri).

But every single Democrat-led state said “Yes”. California, Connecticut, Delaware, Hawaii, New York, Oregon, Rhode Island, Vermont, and Washington. There aren’t even any Democrat-led states that said “Maybe”.

Perhaps it is simplest to summarize this in another table. Each row is a party configuration (“Democrat, Republican”, or “mixed”); the column is a Medicaid decision (“Yes”, “Maybe”, or “No”); in each cell is the count of how many states that fit that description:

	Yes	Maybe	No
Democrat	9	0	0
Republican	4	5	14
Mixed	8	7	3

Shall I do a chi-square test? Sure, why not? A chi-square test of independence produces a p-value of 0.00001. This is not a coincidence. Being a Republican-led state is strongly correlated with rejecting the Medicaid expansion.

Indeed, because the elected officials were there first, I can say that there is Granger causality from being a Republican-led state to rejecting the Medicaid expansion. Based on the fact that mixed states were much less likely to reject Medicaid than Republican states, I could even estimate a dose-response curve on how having more Republicans makes you more likely to reject Medicaid.

Republicans did this, is basically what I’m getting at here.

Obamacare itself was legitimately controversial (though the Republicans never quite seemed to grasp that they needed a counterproposal for their argument to make sense), but once it was passed, accepting the Medicaid expansion should have been a no-brainer. The federal government is giving you money in order to give healthcare to poor people. It will not be expensive for your state budget; in fact it will probably save you money in the long run. It will help thousands or millions of your constituents. Its impact on the federal budget is negligible.

But no, 14 Republican-led states couldn’t let themselves get caught implementing a Democrat’s policy, especially if it would actually work. If it failed catastrophically, they could say “See? We told you so.” But if it succeeded, they’d have to admit that their opponents sometimes have good ideas. (You know, just like the Democrats did, when they copied most of Mitt Romney’s healthcare system.)

As a result of their stubbornness, almost 3 million Americans don’t have healthcare. Some of those people will die as a result—economists estimate about 7,000 people, to be precise. Hundreds of thousands more will suffer. All needlessly.

When 3,000 people are killed in a terrorist attack, Republicans clamor to kill millions in response with carpet bombing and nuclear weapons.

But when 7,000 people will die without healthcare, Republicans say we can’t afford it.