Today, the conservative organization Opportunity Ohio began touting its report  “Medicaid in Ohio: The Choice is Clear” a report that argues against Governor Kasich’s support for expanding Medicaid under the President’s Affordable Care Act.  However, the report notes on its cover page that it was authored by Jonathan Ingram, Director of Research at the Foundation for Government Accountability, a Florida group with ties to ALEC and the Cato Institute that provided the research that Tea Party Governor Rick Scott unsuccessfully cited to justify his failed attempt to require welfare recipients to be subjected to suspicionless drug testing to maintain their eligibility.

Ingram_hi_resIf Mr. Ingram looks young, it’s because he is, and he’s incredibly unqualified.  He’s only two years out of law school after going straight there after undergraduate school.  Outside of his law degree, he has no advanced degrees specifically on public policy or health care.  He has no relevant work experience regarding Medicaid or health care policy except working on a number of conservative think tanks straight out of law school in 2011.

And that’s not the only reason why his report is a total joke.

Here are the arguments that Opportunity Ohio’s wunderkind lays out:

  1. Able-bodied childless adults have never been—and were never intended to be—eligible for taxpayer-funded Medicaid
  2. Medicaid costs are growing and jeopardizing all other state priorities
  3. Ohio policymakers have no reliable cost estimates on which to base their decision
  4. Expanding Medicaid is unlikely to reduce hospitals’ uncompensated charity care
  5. Medicaid is failing to meet its mission of protecting Ohio’s most vulnerable patients
  6. Medicaid expansion crowds out private health coverage
  7. The federal government is unlikely to keep its funding promises to Ohio
  8. It is unlikely Ohio will ever be able to scale back the size of Medicaid once it expands

I’m not going to go through each one of the arguments of the report, but I just want to hit some aspects of this report as Opportunity Ohio has been the leading critic of Governor Kasich’s support of expanding Medicaid under the Affordable Care Act.  On the first point, so what?  Majorities in Congress decided that it was time to expand Medicaid to include impoverished adults with no children and did so in the Affordable Care Act.  The President signed the bill into law.  Pointing out that it’s an aspect of “new” law under the Affordable Care Act doesn’t make it any less than the law of the land, no matter how much conservatives don’t like such changes.

In claiming that expanding Medicaid is unlikely to reduce hospitals’ uncompensated charity care, the report cites that when Maine expanded its Medicaid program in 2002, it did not reduce by 2011 what hospitals’ reported in uncompensated charity care.  There are two reasons this is heavily misleading.  First of all, the report cites actual dollars and doesn’t adjust to account for overall rising medical costs and inflation (real dollars).  And even more importantly, it doesn’t take into account a major economic factor: the recession.  Not surprisingly, the actually figures shows that the largest yearly increases in charity care occurred in 2009 and 2010 during the Great Recession.  What the report does not even attempt to do is quantify what the levels likely would have been had Maine not expanded its Medicaid coverage.  Just because charity care went up during the recession doesn’t mean that expanding Medicare in 2002 didn’t prevent it from increasing even further.

#5 and #6 is self-contradictory.  On one hand, #5 says Medicaid is a broken system that is horrible for Ohioans to have to rely on medical care coverage.  #6 argues that in expanding Medicaid, it “crowds out” private insurers.  In other words, if you have private insurance, but also qualify Medicaid, people will choose Medicaid.  Even if this were truly accurate (it’s not), why are citizens choosing one over the other necessarily a bad thing (and why are they if #5 is accurate?)  But their sole basis for claiming that Medicaid expansion results in “crowding out” is, again, citing how when Arizona expanded Medicaid, the number of insured Arizonians dropped, and the number of Arizonians on Medicaid rose while its rank of uninsured stayed the same.

Not surprising, the report relies on the time period of 2002 and 2011.  Could it be possible that the recession, alone, could account for the number of people in Arizona going from private insurance to Medicaid?  Absolutely, but the author of the report doesn’t even take the recession into account as the possible cause, not the Medicaid expansion.   It should also be noted that Arizona’s Tea Party Governor Jan Brewer has become one of the strongest advocates of expanding the State’s Medicaid program under the Affordable Care Act.  So, it begs the question why would Arizona’s Governor support it, if the prior expansion wasn’t beneficial to Arizona?

#7 is funny given the source.  Basically, it boils down to: the corporate interests of the Koch Brothers and ALEC might eventually be successful in actually forcing President Obama to cut funding for Medicaid in the never-ended fiscal standoffs one of these days, so why allow Ohioans to enroll in something they’re trying to cut?  But even if they’re right, that argument is defeated by Kasich’s trigger that would allow the State to back out of the expansion if the federal government fails to follow through with the promised funding levels.  And that brings us to their final argument…

#8 is the last, and, derpiest.  It’s actually downright dishonest.  It argues that Ohio can’t count on a trigger to back out of the expansion if the federal government (under #7) actually backs out of its promise to fully fund the Medicaid expansion the first two years and then 90% thereafter.  The reason? During oral arguments before the Supreme Court, the government’s lawyer said that the only option a State would have if it wanted back out of the Medicaid expansion is to back out of Medicaid altogether.  The only problem is that the United States Supreme Court decision after that argument actually blows that argument out of the water.  The Court specifically held that it was unconstitutional for the federal government to require the States to agree to the expansion or risk losing all funding for Medicaid altogether:

As we have explained, “[t]hough Congress’ power to legislate under the spending power is broad, it does not include surprising participating States with postacceptance or ‘retroactive’ conditions.” Pennhurst, supra, at 25. A State could hardly anticipate that Congress’s reservation of the right to “alter” or “amend” the Medicaid program included the power to transform it so dramatically.

In other words, just as the Court held that it was unconstitutional for the ACA to require States to accept the expansion of Medicaid or risk losing all funding for Medicaid as it was an impermissible use of Congress’ ability “amend” the program, the Court would like view the retroactive or postacceptance of Congress altering the funding for the States that do expand it as grounds for the State to withdraw.  While the government’s lawyer was legally correct to argue at the time that the Act provided the ability to pull all Medicaid funding from the States, the Roberts Court removed that threat from the Act.  Roberts’ decision, quite clearly, provides States with a legal argument that it can back out of the expansion of Medicaid under the Act if the federal government fails to live up to its end of the bargain:

We have repeatedly characterized . . . Spending Clause legislation as ‘much in the nature of a contract.‘” Barnes v. Gorman, 536 U. S. 181, 186 (2002) (quoting Pennhurst State School and Hospital v. Halderman, 451 U. S. 1, 17 (1981)). The legitimacy of Congress’s exercise of the spending power “thus rests on whether the State voluntarily and knowingly accepts the terms of the ‘contract.’”

A party in a contract is excused from future performance if the other party has breach the contract.  Any first-year law student knows this, so should Mr. Ingram, but since he’s never actually practice law, maybe he forgot that part.

Whether Ohio expands the Medicaid program is a serious topic, and it requires listening to the voice of serious people.  But Opportunity Ohio does itself, and public discourse in Ohio, a huge disservice when it passes off flawed research from unqualified “experts” such as the author of this study.

Evangelize!
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  • Luke Brockmeier

    This study is hilarious. 4 of his 8 policy recommendations are in the 1115 waiver that goes into effect if we expand Medicaid!

    2 more are unworkable (a provider-run HMO needs providers who want to run a HMO) but easier to accomplish after expansion, and the other 2 are silly.

    And “crowding out” refers to interest rates! You can’t “crowd out” health insurance. He just heard that phrase and thought it was cool.

  • Think.

    Self-described “free market think tank,” Opportunity Ohio, is an ALEC shill. Think Tank? Yeah, right.

  • http://ohio15th.blogspot.com StubbornLiberal

    Mr. Ingram, according to the Illinois lawyer search page, does not carry malpractice insurance. Considering his lack of real experience and facts, he should restrain himself in offering his opinions.

  • Retrofuturistic

    Translation: ALEC is opposed to Medicare expansion. All money must move upward to the one percent. It must not go anywhere else.

  • missskeptic

    #5: Medicaid is failing to meet its mission of protecting Ohio’s most vulnerable patients. Kind of hard to fulfill your mission if there’s not enough funding, right?

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