Medicaid expansion and the human cost of political polarization

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.

How (not) to talk about the defense budget

JDN 2457927 EDT 20:20.

This week on Facebook I ran into a couple of memes about the defense budget that I thought were worth addressing. While the core message that the United States spends too much on the military is sound, these particular memes are so massively misleading that I think it would be irresponsible to let them go unanswered.


First of all, this graph is outdated; it appears to be from about five years ago. If you use nominal figures for just direct military spending, the budget has been cut from just under $700 billion (what this figure looks like) in 2010 to only about $600 billion today. If you include verterans’ benefits, again nominally, we haven’t been below $700 billion since 2007; today we are now above $800 billion. I think the most meaningful measure is actually military spending as percent of GDP, on which we’ve cut military spending from its peak of 4.7% of GDP in 2010 to 3.5% of GDP today.

It’s also a terrible way to draw a graph; using images instead of bars may be visually appealing, but it undermines the most important aspect of a bar graph, which is that you can easily visually compare relative magnitudes.

But the most important reason why this graph is misleading is that it uses only the so-called “discretionary budget”, which includes almost all military spending but only a small fraction of spending on healthcare and social services. This creates a wildly inflated sense of how much we spend on the military relatively to other priorities.

In particular, we’re excluding Medicare and Social Security, which are on the “mandatory budget”; each of these alone is comparable to total military spending. Here’s a very nice table of all US government spending broken down by category.

Let’s just look at federal spending for now. Including veterans’ benefits, we currently spend $814 billion per year on defense. On Social Security, we spend $959 billion. On healthcare, we spend $1,018 billion per year, of which $536 billion is Medicare.

We also spend $376 billion on social welfare programs and unemployment, along with $149 billion on education, $229 billion servicing the national debt, and $214 billion on everything else (such as police, transportation, and administration).

I’ve made you a graph that accurately reflects these relative quantities:


As you can see, the military is one of our major budget items, but the largest categories are actually pensions (i.e. Social Security) and healthcare (i.e. Medicare and Medicaid).

Given the right year and properly adjusted bars on the graph, the meme may strictly be accurate about the discretionary budget, but it gives an extremely distorted sense of our overall government spending.

The next meme is even worse:


Again the figures aren’t strictly wrong if you use the right year, but we’re only looking at the federal discretionary budget. Since basically all military spending is federal and discretionary, but most education spending is mandatory and done at the state and local level, this is an even more misleading picture.

Total annual US military spending (including veteran benefits) is about $815 billion.
Total US education spending (at all levels) is about $922 billion.

Here’s an accurate graph of total US government spending at all levels:


That is, we spend more on education than we do on the military, and dramatically more on healthcare.

However, the United States clearly does spend far too much on the military and probably too little on education; the proper comparison to make is to other countries.

Most other First World Countries spend dramatically more on education than they do on the military.

France, for example, spends about $160 billion per year on education, but only about $53 billion per year on the military—and France is actually a relatively militaristic country, with the 6th-highest total military spending in the world.

Germany spends about $172 billion per year on education, but only about about $44 billion on the military.

In absolute figures, the United States overwhelms all other countries in the world—we spend as much as at least the next 10 combined.

Using figures from the Stockholm International Peace Research Institute (SIPRI), the US spends $610 billion of the world’s total $1,776 billion, meaning that over a third of the world’s military spending is by the United States.

This is a graph of the top 15 largest military budgets in the world.


One of these things is not like the other ones…

It probably makes the most sense to compare military spending as a portion of GDP, which makes the US no longer an outlier worldwide, but still very high by First World standards:


If we do want to compare military spending to other forms of spending, I think we should do that in international perspective as well. Here is a graph of education spending versus military spending as a portion of GDP, in several First World countries (military from SIPRI and the CIA, and education from the UNDP):


Our education spending is about average (though somehow we do it so inefficiently that we don’t provide college for free, unlike Germany, France, Finland, Sweden, or Norway), but our military spending is by far the highest.

How about a meme about that?