Background on ACA and Medicaid Expansion
The 2,700-page 2010 federal Patient Protection and Affordable Care Act (ACA) included a controversial Medicaid component. For the first time in its 45-year history, Medicaid was being enlarged to cover able-bodied, working-age, childless adults. Even the supportive Congressional Budget Office confessed the expanded Medicaid program would “reduce incentives to work” and “some people will choose not to work or to work less.”
The 50 states were provided a Hobson’s choice on the Medicaid expansion: opt in the untested expansion and don a taxpayer-subsidized halo, or opt out and risk loss of all federal funds for your state’s beleaguered Medicaid program. Some choice.
The U.S. Supreme Court Strikes Mandatory Medicaid Provision
A majority of the 50 states challenged the all-or-nothing Medicaid provision in federal court. The states argued that the coercive do-what-the-federal-government-dictates-or-lose-all-Medicaid-funding decree surpassed the federal government’s reach under the Commerce Clause and disregarded the U.S. Constitutionally-prescribed limited federal government role vis-à-vis the States.
Stunningly, seven of the nine U.S. Supreme Court Justices (Roberts, Breyer, Kagan, Scalia, Kennedy, Thomas, and Alito) found the Medicaid diktat unconstitutional in National Federation of Independent Business v. Sebelius, 132 S.Ct. 2566 (2012), while still upholding the ACA, 5-4, in a tortuous opinion.
The court’s ruling effectively amended the Medicaid provision in the ACA to provide the states a superficially reasonable option without a pronounced downside. After all, the hospitable federal government would pay 100 percent of the costs – initially. Beginning January 2017, those states would pick up a percentage of costs, with the states’ portion increasing over the years. Depending on your tax bracket, political leanings, and appreciation of net present value, the proffered expansion (a) was a no-brainer, (b) seemed close enough for government work, or (c) reeked of snake oil infused nostrum.
Mississippi’s Decision on Medicaid Expansion
Bryant, the savvy son of a diesel mechanic and product of the rural Mississippi Delta, expressed concerns with the expanded program. He feared the state’s growing portion of the distended costs would require “draconian cuts in … education, healthcare, public safety or transportation.” He even postulated a future Republican Administration might amend the program and leave states on the hook for yet another unfunded program. (TPM writer Sahil Kapur, in a January 2, 2014 article, labeled Bryant’s concern a “novel argument based on an unrealistic hypothetical.” Kapur didn’t envision a Republican clean sweep of the White House, Senate and House in the 2016 elections.)
The governor consulted with Lt. Gov. Tate Reeves and Speaker Philip Gunn on the issue. Mississippi opted out of the expansion.
Recently Released Numbers
Projections aside, we now have some real numbers on the Medicaid expansion program. On November 16, 2016, the Foundation for Government Accountability released its report of previously unpublished enrollment information. The numbers are unexpected, staggering, and extortionate. Overall, Medicaid enrollment is more than twice the projections for the 24 reporting states: 11,466,264 actual enrollees rather than the forecasts 5,452,842. California and New York have enrollments 322% and 276 percent, respectively, over projections. Add that to a balanced state budget.
It is, as the FGA reports, “an uncontrollable nightmare.” The Medicaid opt-in states have no choice but to take “limited taxpayer resources away from the truly needy and other core priorities, including education, public safety, and infrastructure.”
Economic Development and Jobs
Which brings us back to Phil Bryant. At a time when pundits were drooling over free money, the former State Auditor questioned the hype. In 2012, Medicaid was already 23.4 percent of Mississippi’s budget. In his 2013 State of the State address, Bryant proposed that instead “of assuming enormous costs that we cannot afford, I would suggest that we spend our time and efforts in finding good jobs for all Mississippians.”
Which he did. In January 2017, Mississippi received the Gold Award from Business Facilities for landing Continental Tire’s $1.45 billion manufacturing plant with 2,500 new jobs – the 2016 Economic Development Deal of the Year in the United States. Continental was a sequel to Yokohama, Top Ship, yet another Nissan expansion, General Dynamics IT, William Sonoma, the Nissan Supplier Park, GRAMMER, Southern Motion, and H.M. Richards. Area Development Magazine now lists Mississippi in the Top 10 States for Doing Business.
As to Medicaid expansion, reasonable minds can differ. The Mississippi State Medical Association, a respected and influential group, strongly supports broadened health care coverage to address a very real public health crisis. Still, the policy issues on how to fix the problems and how to fund the solutions are thorny. Reasonable people should agree that nothing is free, there is a limit to how much we can tax our way to prosperity, and the allocation of the state’s limited financial resources involves difficult and subjective choices.
Phil Bryant, Mississippi’s prescient governor, with the support of Lt. Gov. Tate Reeves and Speaker Philip Gunn, took a reasoned and practical approach. Give a person a fish, and you feed ‘em for a day. Give a person a job, and you feed ‘em for a lifetime.
» Ben Williams the author, is a Mississippi attorney. Email Ben at MBWJ@aol.com. Ford Williams, the artist, is a 2016 honor graduate of Jackson Academy and currently attends the Savannah College of Art & Design (SCAD).