Should States Opt Out of the Medicaid Expansion?

Tuesday, July 03, 2012

Avik Roy, senior fellow at the Manhattan Institute, explains why some states would opt out of the Medicaid expansion portion of the Affordable Care Act. Avik writes The Apothecary blog on health care policy for Forbes.

Comments [43]


Hey Brian: Great show as usual. The ACA will become a great program for all Americans if ever implemented. However, you will never get a Republican to concede one positive comment about ACA as long as grass is green and the sky is blue. But, I give you lots of credit for giving them a chance and posing the best questions. Also, they have their talking points finely honed. No matter how you phrase the question they will always go back the horribles. I hope ACA is fully implemented and then we can look back and say, it was the right thing to do.

Thanks for your show

Jul. 05 2012 05:49 PM

@Eugenia Renskoff from Brooklyn, NY

"Hi, I don't understand why . . . anybody can deny a human being medical care. Good health should be available to every human being in this country and other countries. "

And I expect that the ultimate development of the growing ethic governing healthcare services will see doctors and other personnel required to provide medical treatment chained to their duties until the medical needs of all human beings are treated.

Jul. 04 2012 01:50 AM
PREVENTING the poor from accessing healthcare.

The SCOTUS line item veto of the Medicaid mandate left a hole
in the Healthcare law.

The working poor are NOT eligible (under the rest of the law)
to access the exchanges (b/c they were supposed to be
covered by Medicaid).

This means they are now in their own extraordinarily high
risk 'insurance' pool. Private insurance - even if they
COULD have paid for it (which most cant) - would become
even more prohibitively expensive for them.

If they remain uninsured, they'll pay HIGHER RATES for
the exact same medical services as everyone else - b/c
the poor and uninsured GET CHARGED MORE DUE TO THEIR

So now, the Red-state governors are forcing the working
poor to have virtually NO access to healthcare -
public or private.

Their decisions will literally kill thousands of innocent
American citizens - just to score political points.

Brian - please call them out.

Jul. 03 2012 04:57 PM
Eugenia Renskoff from Brooklyn, NY

Hi, I don't understand why a governor, anybody can deny a human being medical care. Good health should be available to every human being in this country and other countries. Eugenia Renskoff

Jul. 03 2012 02:23 PM
Gary from queens


I appreciate it when you have a conservative on your show, like Avik. You should do it more often. Counterpoint makes a show interesting. For that reason, i hope you appreciate my comments from the right. It contributes to the quality of the show. And i assume you wish to have a show that teaches, and not one which propagandizes.

On the matter of long posts: I stay within the blog softwares limit, obviously. But is it your wish to see mindless one line sound bites that all the networks and talk radio shows prefer? Or do you prefer some level of depth by listeners to your show?

I await your announcement on that.

Jul. 03 2012 12:08 PM

I wish when BLShow would not have these extreme ons-sided interviews on important issues -- especially since BL cannot effectively rebut sweeping assertions and remain a non-partisoan host. Avik Roy should have had a discussion with someone in a position to support the importance of the medicare provision. But one fact not brought up is that the hospitals stand to lose in states that reject opting in to the Medicare plan -- and they will definitely become a player as this moves forward.

Jul. 03 2012 11:22 AM
Sheldon from Brooklyn

Will, you simply do not understand the point of Federalism...and that's a bloody shame...

Jul. 03 2012 11:20 AM
Amber Pinter from Fayetteville, Arkansas

Please realize what these numbers say about poverty in Arkansas - 771,000 already on Medicaid + the 250,000 expected new enrollees = 1 MILLION Arkansans under age 65 living at or under 138% of the poverty level. That's over 40% of our state population of 2.4 million.

Thank goodness for the PPACA and our Gov. Beebee - a southern Democrat who is accepting the federal support to extend coverage to our very many, very poor citizens.

Jul. 03 2012 11:07 AM
Will Miles from Morris Plains, NJ

Brian, please have your staff fact-check this guest's stats and assertions. He is articulate but clearly biased.

From my perspective--just as with the Electoral College--the concept of the need for states to have the freedom to establish laws and regulations different from the Federal laws and regulations is not only unnecessary, it is destructive and counterproductive.

Jul. 03 2012 10:59 AM
NER from NJ

The Manhattan Institute guest claimed that Medicaid recipients can't see doctors easily because the reimbursement rates are too low. That's one of the problems that the Medicaid expansion addresses, but the guest conveniently forgot to mention it.

In addition to the federal funding to cover the cost of expansion (100% in the first two years, then declining slightly until it remains at 90% in 2020 and thereafter), the Affordable Care Act will "increase Medicaid payment rates to primary care doctors to match Medicare payment rates, which are higher, in 2013 and 2014."


Jul. 03 2012 10:58 AM
Leo from Queens

YES!!. They should opt out - The goal of the oligarcy and plutocracy in this country is for us to become one of the most unequal Third World countries in the World. The fastest way to achieve that is to ensure that the majority of people in each state are as poor as possible without access to education or health care unless they have money.
It makes perfect sense if we are to quickly achieve the goals of the oligarchy and the buffons they have put in charge of Congress and many of these states

Jul. 03 2012 10:57 AM
Sheldon from Brooklyn

If Obama were serious, he should have tried harder for a federally run single payer/public option, or leave it up to States to set up their own systems.

"Forcing" states to accept carrot and stick mandates as this muddled "Obamacare" does, is the worst of both worlds.

Jul. 03 2012 10:55 AM
Yoichi Hariguchi from Menlo Park, CA

The guest's comment on Medicaid is incorrect. Take a listen to this report by the Planet Money team. Brian should invite Alex and talk about the same issue.

Don't trust any study without having a control group.

Jul. 03 2012 10:55 AM
Paul from White Plains

As for the actions of these governors, The Rev. Dr. Martin Luther King Jr used two words, nearly a half century ago, to describe similar actions of states, blocking laws of the United States: interposition and nullification. We have not come very far in fifty years.

Jul. 03 2012 10:54 AM
Taher from Croton on Hudson

I have turned off the Radio for the moment. I am sick of listening to these twist clowns form the Manhattan Institute who are supporters of corny capitalism, and corruption.

Jul. 03 2012 10:52 AM
Scotty Watson from Secaucus

Every time Avik Roy says the words "some studies," I assume that everything that follows is a lie. By the way, I am originally from Canada where the Health Care System works GREAT!

Jul. 03 2012 10:51 AM
M. L. from New York, NY

Is this guy insane? I think he said someone who is uninsured will pay a doctor for better care than someone on Medicare, because many doctors don't accept Medicare. I don't understand how someone who is uninsured can even afford to go to the doctor, much less pay for "better" care.

Jul. 03 2012 10:49 AM
Sam from Manhattan

How does this affect illegal aliens? They obviously would not pay a penalty, so if they show up uninsured at a hospital how does this fix anything, the costs are still passed on to the rest of us.

Jul. 03 2012 10:48 AM
Amy from Manhattan

It may not be "free," but it will already be paid for through existing federal taxes. So why not get some of that money back?

Jul. 03 2012 10:48 AM

Physical condition of the state, as opposed to that of the people of that state......???
Dumb Logic.
A state is nothing without it's people to pay the bills.... How long will people stay in a state that
does not protect them.


Please this guy should go back to his religion and read it's book of morals or whatever!

Does this guy even know the reason for government?

incidentally, why do
Canadians in the US, go back to Canada for their health care?

Jul. 03 2012 10:48 AM
john from office

This issue is an example why the average person hates politics. What are the facts, the truth, not spin.

Jul. 03 2012 10:48 AM
Juan from White plains

It's only poor people. Who care if the have some health ins. Coverage???

Jul. 03 2012 10:47 AM
Jed from Inwood

The same Oregon study that your guest just cited pretty well discounted the claim that he made a minute ago that the UNinsured have better health outcomes than those on Medicaid. Didn't it?

Jul. 03 2012 10:47 AM
GW from Manhattan

Healthcare is not a cost it's a market and as a market it generates revenue. Arguments against market creation made by the anti health care fools are anti market tomes that think that the health care market generates no positive economic activity. Every "cost" = money moving around. And every movement of money means tax revenue and jobs and wealth. The federal government does not borrow money from China. this idiot on the phone can't provide a logical argument. He is a propagandist.

If tomorrow we eliminated Healthcare from our economy, if some space alien came down and used a "health ray" to make us all completely healthy and well forever, our economy would collapse. (good buy Duane read and CVS) When we calculate the amount of wealth that the health care economy generates thru jobs and goods and services ( and the taxes that al the health care workers pay from super rich surgeons to the lowly hospital or clinic orderly) Healthcare is not a tax, it is not a cost, it is a vital part of the economic engine that provides income for tens of millions. I have medicaid and I have no problem seeing a doctor. Forbes magazine lies and will make up any thing that it can to argue against universal health care.

Jul. 03 2012 10:45 AM
Amy from Manhattan

I heard yesterday on 1 of the programs on WNYC that the federal contribution would go down to 95%, not 90%, after the 1st 3 years, & then decline in increments until it was the same as the current percentage (around 55%?).

Jul. 03 2012 10:44 AM
Taher from Coroton on Hudson

The Fact is that the Republicans, since the end of the Civil War, could not give a damn about the American people. Not surprisingly, Republicans are against universal, affordable health care for all in this country. Though, without a universal coverage many hospitals through out the country will go bankrupt due to overwhelming use of emergency care by those who do not have health care coverage.
The Republican governor of Florida is damned liar.

Jul. 03 2012 10:44 AM
Martin Chuzzlewit from Manhattan

Governor Scott Walker will be at the Manhattan Institute on Monday addressing this and other issues.

Jul. 03 2012 10:44 AM
Latisha from Bronx

How will everyone be insured? Will people who are not registered tax payers suddenly sign up for health insurance? Don't think so. Will illegal residents be turned away from hospitals? or is this just a bogus argument.

Jul. 03 2012 10:44 AM

So Republican governors will allow it's taxpayers to underwrite the expansion of Medicaid for the rest of the country but not insure any of its own state's needy? And then still have to cover local emergency room costs for uninsured? What a bargain!

Jul. 03 2012 10:43 AM
Bob from Westchester

The guest is not counting the savings to the state for not having to reimburse hospitals for services to uninsured patients - which they bill at the full retail price, not the discounted prices that United Healthcare, et al negotiate for their customers.

Jul. 03 2012 10:42 AM
Juan from White a plains

What is the cost of Not having insurance???

Jul. 03 2012 10:42 AM

Brian, please ask your guest: what happens to the figures cited by these Republican governors when the high cost of providing routine medical care to the uninsured in hospital emergency rooms is figured in, i.e., the high but hidden costs of our current (non-)system?

Jul. 03 2012 10:42 AM
Moishe from Brooklyn

-> raylene, unfortunately, brian rarely asks these types of hard hitting questions on things he agrees with as we've seen the last few shows - even just to play devils advocate.

Jul. 03 2012 10:42 AM

This guys is an obfuscating tool shed ignoring the implicit MORAL issues of telling millions of people, "Nope, sorry. No insurance for. Hope you don't get sick, and if you do——try and die fast and don't use an ER. Thanks."

Jul. 03 2012 10:42 AM
Sheldon from Brooklyn

There is no such thing as "free" health insurance.

The Feds have no business mandating the States to provide healthcare. This is what happens when they try.

Jul. 03 2012 10:40 AM

So never try to do anything good because tomorrow the money might disappear? That is the most pessimistic life view I've ever heard!

Jul. 03 2012 10:39 AM
BK from Hoboken

Re governor of WI discussing this as a huge new tax: here is how you avoid the tax- accept the program. The people eligible for the expanded Medicaid program won't have to pay to the tax if you allow them to enroll!!! What an idiot. YOU are the one costing your citizens more money! YOU are the one who will hoist a huge amount of payments for hospital charity care onto your citizens that could be eliminated by those patients having insurance! How stupid do these politicians think we are?!

Jul. 03 2012 10:39 AM
Raylene from Queens

Brian, why do you ask like this is free money... we are borrowing/printing/taxing for it. Guess which states will cover a lot of the cost due to their higher income, NY, NJ, CT, etc. I know you are partisan but please look at this a little more even handedly.

Jul. 03 2012 10:38 AM
Sheldon from Brooklyn

Gary doesn't care that no one will actually read his cut and paste rants...

Jul. 03 2012 10:37 AM
Martin Chuzzlewit from Medicare

Even wimpy David Brooks calls this state burden a disaster in his NY Times column this morning -

"Another report from the department (HSS) suggests that there could be 84 million (!) Americans on Medicaid, an astounding burden on that already stretched system."

Jul. 03 2012 10:31 AM
john from office

Gary, this space is for comments, not novels. You comments are so long, no one will read them. It gets tedious.

Jul. 03 2012 08:47 AM
gary from queens

By The Way:

On the same day (yesterday) that Avik's essay was published ("Obamacare: The Final Battle"), and in the same publication (, Andy McCarthy had written an article about the Arizona decision that was announced last week-----3 days prior to the Obamacare decision. But as you read the following excerpt from Andy, it could very easily be applied to point Avik makes about the states' position on Medicaid expansion:

There are all kinds of powers that are shared in a system of dual sovereignty. When they conflict, it is not a given that federal power must prevail. Contrary to what appears to be a bipartisan consensus, the Supremacy Clause does not mean federal power always wins; it means the Constitution always wins. The Constitution does not subordinate the states and the people to the federal government; to the contrary, its main objective is to suppress the federal government, to cabin its powers to a few, limited areas of national concern. Progressives are trying to save the world, but the Framers were more concerned about saving the states.

Jul. 03 2012 05:16 AM
gary from queens

Avik Roy notes the hazards of government deception through mislabeling, in his July 2, 2012 essay, "Obamacare: The Final Battle"

The law’s requirements that plans cover a government-approved list of “minimum essential benefits” requires that every American will have to pay for things he or she isn’t likely to consume, like acupuncture and substance-abuse services. It’s like going to a restaurant where you’re forced to have a seven-course meal when you would have been just fine with three, and you don’t like salmon anyway.

Indeed, by the very act of subsidizing insurance, the law drives up its cost. If you were given a clothes subsidy, would you spend the same amount on clothes as you did before, or splurge from time to time? The laws of economics don’t magically go away when you buy health insurance. One of the costliest aspects of the law is that it requires all plans on the new exchanges to have a generous financial value, called a “minimum actuarial value,” that will force everyone to buy costlier insurance.

Not the typical complaint of calling something a tax when its really a penalty. Avik's point is more tangible in its economic impact----that of the government calling something "insurance" that is not at all insurance. While the former is dispositive for Constitutional analysis, the latter gets to the very heart of the actuarial achilles heel of managed-care generally, and its version on steroids----obamacare.

He writes, for example, that the average family under Obamacare will pay a 9 percent increase in premiums, instead of Candidate Obama's promise that premiums would decrease $2,500 per family. And, he writes that Obamacare "rations Medicare. It forces between 17 and 25 million more people into Medicaid, a program with some of the worst health outcomes in the world, in which people die of toothaches because they can’t gain access to care. It raises taxes by more than $500 billion over ten years."

On that basis, I expect Avik will point out why some states cannot accept the Medicare expansion-----because unlike the federal government, states cannot print money. They must live within their means.

Jul. 03 2012 05:13 AM

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