Obamacare, where did our love go?

“[Medicaid expansion] you came into my heart
So tenderly
With a burning love
That stings like a bee”
          -“Where Did Our Love Go,” The Supremes, 1964

The following is in response to a recent post that appeared on Utah Poverty News, entitled: “On the issue of Medicaid expansion, like so many things, we can’t go back to 1964.”

We appreciate the opportunity to respond to recent points and to clarify why Medicaid expansion is so worrisome a path for Utah to follow. In a humorous critique of our recent letter opposing Medicaid expansion, proponents of Medicaid expansion imply that our opposition is misplaced and that we would have to go back in time to 1964 when Medicaid was first started to fix our frustrations. This is not so. Medicaid expansion on its face represents significant federal micromanagement in state health care policy and has proved disastrous for many states. The line from The Supremes’ 1964 hit “Where did our love go,” referenced above, describes the problems already being felt by Medicaid expansion in some states. The promises from Washington were rosy and “tender” as they penetrated the “burning” hearts of state lawmakers around the country, but the result of implementation has, “like a bee,” stung state budgets and the truly needy.

At least 7 of the 29 expansion states have experienced cost overruns as enrollment projections were vastly under-predicted. More troubling is the way in which expansion has left state programs strapped for cash and unable to provide critical care to those most medically needy. Moreover, as more enrollees seek care from a limited pool of doctors that accept Medicaid, needy patients will find themselves further and further down the waiting list for actual care. While the temptations of rosy feelings of love for a program that promised so much for so little led states to expand, the fiscal and economic realities for these states have ruled supreme and couldn’t “get us” or “make us love” it in the end.

The critique of our letter ridicules our request for lawmakers to “find a way out from under Washington, D.C.’s thumb” by claiming we need to go back to 1964 to reverse the decision to enact Medicaid in the first place. However, expansion under Obamacare is not the Medicaid of 1964. The original plan gave states the power to administer the program with flexibility to structure eligibility and benefits how they saw fit.

Medicaid expansion under Obamacare prescribes many of the particulars in how Utah can expand Medicaid. It is not the case that Medicaid funds are given as block grants (as has been claimed by some in Congress, including Utah Senator Orrin Hatch) to the states to best solve the problems of health care for the needy in their states based on their unique circumstances. Instead, the federal government is micromanaging how the program itself is structured and administered.

Utah must seek a flexibility waiver from the administration in order to expand Medicaid in a way different from the prescribed one-size-fits-all method under Obamacare. This is a quintessential example of being “under D.C.’s thumb.”

The Governor early on, and now the “Gang of Six,” have all had to travel to D.C., hat in hand, to negotiate and plead for flexibility to spend dollars allocated to Utah our own way. This hampers Utah’s ability to decide the best way to help the needy under a “state-based” expansion of the Medicaid program, as opposed to the way mandated under Obamacare. To say that those who think this is a heavy-handed Washington D.C.-centric approach want to “go back to 1964” misses the fundamental problem of Obamacare: federal micromanagement of programs and regulations that were originally sold as being “state-based.” This is indicative of the entire health care law and its top-down approach.

The Poverty News post also states, “Since then [1965], the federal government has provided most of the money used to pay for healthcare services for vulnerable Americans.”

The federal government does not have its own money. This might only be true when the federal government essentially prints its own spending money, monetizes federal debt, or perhaps issues new debt. Otherwise, the federal government gets its “money” from the people of the states. Make no mistake: the “money” for Medicaid, both in 1964 and now, is from the people of Utah—confiscated through federal taxes and then sent back (minus a sizable chunk for the middlemen) to states with strings attached that govern how it is to be spent. It is not a magnanimous gift from the President. It does not grow on a magical federal money tree. It is simply the funneling of hard-earned dollars, taken through taxation, being spent at the direction of lawmakers and bureaucrats thousands of miles away. Unfortunately, it doesn’t stop there—many of these dollars will be our children and grandchildren’s hard-earned dollars as well.

Utah lawmakers can get out from under the “thumb” of D.C. by refusing to take the expansion dollars and finding a solution that doesn’t require dancing at the end of Obamacare’s strings. “Frail Utah” was one such alternative. Another is to highlight publicly exactly what is being said by the administration in regards to granting a flexibility waiver. Bring some needed transparency to the “most transparent” White House in history and let America know exactly how Obamacare dictates terms to states using the dollars of the people of those states as a club. Moreover, if Utah gets a flexibility waiver, it must get one only on the very best terms possible based on all previous states and current negotiations with Virginia. Cost-sharing, work requirements, and other truly state-based solutions should all be on the table. From our understanding, the “thumb” of D.C. is not open to these items.

Dear Obamacare: unlike the beats of Motown, your dictates and implementation have not been smooth and enjoyable. For states in your wake, it has been more of a woe-town experience.