Last Friday, the U.S. Department of Health and Human Services (HHS) announced that it would allow states to pursue waivers letting them privatize their Medicaid expansions under Obamacare — an idea that took root with a deal worked out by Arkansas Gov. Mike Beebe (D) and the Obama HHS last month. Commentators and policy-makers heralded it as a “game-changer” for the reform law, as it could influence red states — many of which have high poverty levels and massive uninsurance rates — to extend coverage to poor people and help facilitate a major Obamacare provision.

But as Medicaid policy expert and George Washington University professor Sarah Rosenbaum smartly pointed out to the Washington Post’s Sarah Kliff in March, using federal dollars to put Medicaid-eligible populations into privately-contracted plans isn’t a novel concept at all — to the contrary, states have actually been doing it for decades through their increasing use of Medicaid managed care (MMC) arrangements. These arrangements contract beneficiaries’ care out to private insurers and providers, and a full “two-thirds of Medicaid enrollees now receive most or all of their benefits in managed care.”

Republicans have historically been strong proponents of MMC, touting its potential to cut costs while protecting poor Americans’ benefits. But with HHS’s new offer to institute a wide-scale version of this program now on the table, several notable Republicans are balking at the idea — including some who have pushed for similar measures themselves in the recent past:

1. TEXAS GOV. RICK PERRY. The 2012 presidential aspirant has been on an anti-Medicaid bender of sorts lately, declaring that “Texas will not be held hostage by the Obama administration’s attempt to force us into the fool’s errand of adding more than a million Texans to a broken system.” Yet, during his presidential run in late 2011, Perry struck a massive deal with federal officials allowing him to move close to a million Medicaid beneficiaries into managed care. Perry heralded the move in a press release, saying, “By approving Texas’ Healthcare Transformation and Quality Improvement Program Waiver, state and local officials can provide more efficient and effective care, and implement locally-tailored health solutions.” Apparently, Perry doesn’t view the Obama Administration’s offer on privatized Medicaid to be a similar opportunity for implementing “locally-tailored” solutions.

2. LOUISIANA GOV. BOBBY JINDAL. One of Obamacare’s most ardent critics, Jindal has steadfastly refused to expand Medicaid in his low-income state, saying that “Medicaid still operates under a 1960s model of medicine with inflexible, one-size-fits-all benefits and little consumer engagement and responsibility.” So far, he has stuck by that decision despite the urging of local lawmakers and his own state’s hospital chains. But back in 2011, Jindal aggressively — and successfully — pushed through an expansion of Louisiana’s MMC program, shifting 900,000 Medicaid and CHIP beneficiaries onto private, managed care. The measure was actually Jindal’s number one health care-related priority for 2012, and his administration publicly sold it “as a way to save taxpayer money and provide better care through coordination among doctors, hospitals and other medical professionals.”

3. MISSISSIPPI GOV. PHIL BRYANT. In an interview with Kaiser Health News, the Mississippi governor said, “I would rather pay extra to Blue Cross [to help cover uncompensated costs for the uninsured], rather than have to raise taxes to pay for additional Medicaid recipients” — a tacit endorsement of a managed care scheme. In fact, in 2012, Bryant signed a bill allowing Mississippi’s Medicaid division to increase the proportion of beneficiaries who could be placed onto managed care programs from 15 percent to 45 percent of the aggregate pool. Bryant has attributed his opposition to Medicaid expansion to his view that the program disincentivizes people “to find a better job, or to go back to school, or to get [into] a workforce training program.”

Texas Gov. Rick Perry (R) and the state’s two Republican senators, John Cornyn and Ted Cruz, joined forces at the state capitol on Monday afternoon to reiterate their opposition to expanding the Medicaid program under Obamacare. Despite the fact that Texas could add about 1.5 million low-income people to its Medicaid rolls if lawmakers opted to expand the program, the state’s GOP leaders still refuse to do so.

“Seems to me April Fool’s Day is the perfect day to discuss something as foolish as Medicaid expansion, and to remind everyone that Texas will not be held hostage by the Obama administration’s attempt to force us into the fool’s errand of adding more than a million Texans to a broken system,” Perry said of the health reform law’s initiative to ensure that poor Americans have access to the medical care they need by standardizing Medicaid eligibility levels across the nation.

More than 25 percent of Texans don’t have health care, one of the highest rates of uninsurance in the United States. That’s partly because the state’s Medicaid program is currently one of the most restrictive — requiring a family of three to earn less than $5,000 per year, far below the federal poverty line, to qualify for public health insurance. But the Republicans in the state want to make it clear that’s not going to change anytime soon.

Although eight other GOP governors have now endorsed the health law’s optional Medicaid expansion, the GOP lawmakers in Texas are happy to buck that trend. “I am proud that Gov. Perry and other Texas leaders are standing strong to oppose Medicaid expansion under Obamacare, while so many other states are giving in,” Cruz said at Monday’s press conference. Earlier in the day, Cruz suggested that Obamacare’s Medicaid expansion is so expensive that it will prevent states from fully funding their prison systems and keeping violent criminals off the street.

Not everyone in Texas agrees with the Republican Party’s decision to reject Obamacare’s Medicaid expansion, however. A counter event — spearheaded by Rep. Joaquin Castro (D-TX), and his identical twin, San Antonio Mayor Julián Castro (D) — followed the governor’s press conference, as advocates for health care reform spoke out about the importance of expanding Texas’ social safety net. The Castro brothers were joined by a diverse coalition of faith-based organizations, labor groups, the Texas Hospital Association, and other Democratic lawmakers, all of whom have been lobbying for Medicaid expansion over the past several months.

One concern consistently raised by Obamacare skeptics is the effect that the law’s optional Medicaid expansion will have on the limited supply of physicians in the United States. Some argue that a rush of newly insured low-income Americans into the health care system will overwhelm physicians, forcing them to work unsustainable hours. But a new study conducted by researchers at the Government Accountability Office (GAO) and the Center for Studying Health System Change suggests otherwise. Researchers point out that the creation of the Children’s Health Insurance Program (CHIP) in 1997 — which was a similar expansion of a health entitlement program — didn’t lead to such negative consequences, and even had the exact opposite effect in certain cases.

The “demand-driven” model of health care consumption theory assumes that greater access to care will lead to greater consumption of health care services, forcing doctors to work longer hours to meet the increased demand. But, according to report authors Fang He and Chapin White, that’s not what happened with CHIP. The new study concluded that CHIP’s implementation actually led to pediatricians working significantly less hours in states that had the most robust CHIP programs, with a 5 percent increase in the enrolled pool correlating with a 14 percent reduction in hours worked:

“These findings are clearly inconsistent with the hypothesis that physicians will work longer hours to accommodate an influx of demand following a coverage expansion,” He and White wrote. “What is less clear is whether the association we find is causal and, if so, why pediatricians would actually work fewer hours in response to a coverage expansion.”

They speculate that there could be two reasons: CHIP reduced average reimburse rates for pediatricians that led them to reduce their hours; or, the shorter hours are a reaction to the managed-care nature of CHIP and its gatekeeper mechanisms.

Assumptions that healthcare is a demand-driven model in which physicians provide the volume of service patients demand “rest on very shaky ground,” the report stated. In contrast, a supply-driven model includes physicians treating patients with a variety of insurance arrangements and tailoring their practices to the financial incentives those arrangements create. The researchers cite a 2009 finding that reimbursement for an office visit for a child on private insurance was $81 compared to $47 for a child enrolled in Medicaid or CHIP. [...]

The data is not conclusive, and the methodology is imperfect. But the study does demonstrate a point that often gets overlooked in health care policy debates: Massive systemic changes do not occur in a vacuum, and the assumption that current health care trends will proceed in perpetuity despite ongoing policy changes is a flawed one.

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States that expand their Medicaid programs under a provision in the Affordable Care Act will be forced to open their prison doors and allow violent criminals to roam the streets, Sen. Ted Cruz (R-TX) claimed during a radio interview on Monday, insisting that the cost of providing health care to lower-income residents would reduce state funding for priorities like incarceration or education.

Appearing on 550 KTSA to promote an event touting Gov. Rick Perry’s (R-TX) opposition to the health care law, Cruz explained that expanding Medicaid would “put enormous financial pressures on the state” since the federal government’s share of financing coverage for Americans up to 133 percent of the poverty line starts at 100 percent in 2014, but then “goes down and down and down”:

CRUZ: And it will become a bigger and bigger part of the state budget and so if Texas did as some other states are doing and signed on to the expansion of Medicaid, what we would see is Medicaid growing even faster than it is now as a percentage of the state budget and crowding out every other priority. So if you think it’s important for the state to continue spending on public education, you should be glad that the state is not signing on to Medicaid expansion. If you want state funds to provide for our prisons and law enforcement to incarcerate violent criminals and keep them off the streets you should be glad we’re not signing up for this Medicaid expansion because every state that does so is going to be regretting it mightily because the pressure is going to crowd out just about every other priority in the budget.

Under the Affordable Care Act, the federal government fully funds Medicaid expansion until 2016 and gradually reduces its contribution to 90 percent in 2020 and subsequent years. Texas would never pay more than 10 percent of the cost of expansion, while extending coverage to more than 1.5 million uninsured Texans and saving millions in costs to taxpayers of caring for the uninsured.

For instance, a recent analysis from the Perryman Group found that Medicaid expansion could provide substantial economic stimulus — the state would contribute “$15.6 billion over a 10-year period, while receiving $20.0 billion in revenue” from increased economic activity and productivity. The report found that for “every dollar spent by the State for additional Medicaid coverage, total spending in the economy would go up by $43.50, output (real gross product) would rise by $21.72, personal income would grow by $14.34, and retail sales would expand by $6.13.”

Eight Republican governors have endorsed Medicaid expansion.

For years, researchers have documented the fact that uninsured people — who are predominately Americans living at or near the federal poverty line — face significantly increased risk for serious health problems over their lifetime. The Affordable Care Act takes the first step in addressing health disparities for poor Americans by expanding Medicaid coverage to all people with incomes up to 138 percent of the poverty line — $15,856 for individuals and $32,499 for a family of four in 2013. Nearly 17 million people are projected to gain coverage through the Medicaid expansion if all states participate.

But at least 13 states have indicated they will not expand Medicaid and several more are on the fence, posing a substantial threat to the ACA’s expansion of insurance coverage for the most economically vulnerable Americans.

The New England Journal of Medicine published a study late last year that demonstrates the life-saving potential of Medicaid coverage for low-income Americans. The study analyzed the effects of Medicaid expansion on adult morality in several states that had expanded coverage before the Affordable Care Act and found that Medicaid expansion was associated with a 6 percent reduction in mortality over five years for adults between the ages of 20 and 64. In other words, for many Americans, the difference between having access to Medicaid and not having access to Medicaid may literally be the difference between life and death:

The study adds to a growing body of research that demonstrates the (fairly intuitive) correlation between insurance, access to health care, and averted mortality. The Institute of Medicine, the Urban Institute, and other researchers and experts have documented either the potentially life-saving effect of Medicaid coverage or increased mortality rates among the poor and uninsured. While study design of the New England Journal piece cannot demonstrate with finality that Medicaid directly reduced the number of deaths in each state, it represents a methodologically rigorous assessment that rules out many of the other plausible explanations for the decreased death rate in states that expanded Medicaid coverage compared to those that did not expand coverage.

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Our guest blogger is Lindsay Rosenthal, a Research Assistant for Health Policy and Women’s Health and Rights at the Center for American Progress.

Low-income Americans in the South, where states impose some of the nation’s most restrictive Medicaid eligibility requirements, are being forced to put off the medical care they need because they can’t afford it. According to a new study from the New England Journal of Medicine, the American adults who don’t qualify for Medicaid assistance in their states are simply forgoing care — an issue that Obamacare’s Medicaid expansion, which seeks to extend public health insurance to the low-income people who can’t currently qualify for it, can help address.

Obamacare’s expansion seeks to standardize Medicaid eligibility levels throughout the country, since there’s currently a huge range of different Medicaid eligibility rates across different states. Some states define Medicaid eligibility so narrowly that families of three making just $5,000 per year aren’t considered poor enough to access public health insurance. Researchers used county-level data to confirm — predictably — that the low-income people in those states are less likely to get medical care. The problem was the worst in Florida and Texas, which have the greatest prevalence of residents delaying their health care services:

As the map shows, the county-level prevalence of delayed care has huge ranges across the country. Just 6.5 percent of the people in Norfolk, MA, are putting off their medical treatment, compared to a staggering 40.6 percent of the people who live in Hidalgo, TX.

Those numbers are directly related to whether states are defining their Medicaid pools by Obamacare’s expanded definition, and allowing people with annual incomes up to 133 percent of the federal poverty line to access coverage. In states that have set their Medicaid eligibility levels at or above 133 percent of the federal poverty line, fewer people are delaying care. If every state accepted the health law’s expansion of the program, each Medicaid program would be set at that level, and the map above wouldn’t have nearly as much variation.
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Arizona Gov. Jan Brewer, a vocal opponent of President Obama’s health reform law, surprised her Republican colleagues when she announced her support for Obamacare’s Medicaid expansion at the beginning of this year. Since then, Brewer has been attempting to broker a deal with the legislators in her state, who will ultimately need to approve the legislation to expand the public health insurance program.

And as negotiations over Arizona’s Medicaid expansion plan go back and forth, some of the state’s powerful lobbyists are attempting to attach amendments to the proposal to suit their own interests — including a totally unrelated attack on Planned Parenthood, which has become a symbol in the GOP’s ongoing crusade against women’s health.

Obamacare proponents warn that additional amendments could threaten to derail the whole expansion process altogether, since Democratic lawmakers may not be willing to pass a bill with unrelated riders. Nonetheless, one of the state’s most powerful lobbying groups is jumping on the opportunity to target Planned Parenthood, regardless of the potential consequences for Arizona’s low-income residents who may be forced to go without health care if the expansion doesn’t go through:

The Center for Arizona Policy is using an opinion from the Arizona-based Alliance Defending Freedom, a Christian legal-defense organization, to argue that the draft Medicaid legislation should be amended to disqualify the non-profit women’s health provider Planned Parenthood from receiving public money. [...]

[Cathi Herrod, the center’s president] said her organization, a conservative Christian-based group that wields influence with GOP lawmakers, is not taking a position on Medicaid expansion and wouldn’t comment on the possibility that such an amendment could sink the plan.

“Our request is to include language guaranteeing that no funding to an abortion provider results from Medicaid expansion,” Herrod said. “Any dollar that goes to an abortion provider for any service frees up another dollar to subsidize abortion.”

Planned Parenthood gets a fraction of its funding from Medicaid but could pick up more patients if the state broadens eligibility. Although Herrod argues that funding to the clinics indirectly supports abortion, Planned Parenthood officials say they lose money on every Medicaid patient because of reimbursement levels.

The proposed amendment to Arizona’s Medicaid expansion is very similar to a measure that Brewer signed into law last year, which also sought to prevent federal Medicaid dollars from going to Planned Parenthood. Last month, a federal judge blocked that law from taking effect — since state-level Medicaid programs cannot exclude qualified providers from providing essential heath care to the low-income Americans who need it, Arizona is not permitted to target Planned Parenthood simply because the national organization performs abortions.

But even Arizona’s failed record won’t deter the abortion opponents in the state from continuing to go after Planned Parenthood. Bryan Howard, the president of Planned Parenthood Arizona, sharply criticized the Center for Arizona Policy and Herrod for pursuing a “failed legislative strategy” that could jeopardize the state’s Medicaid expansion. “She has to know that she is putting health-care access for 400,000 people at risk,” Howard told the Arizona Republic.

Gov. Bill Haslam (R-TN) announced on Wednesday that he will not pursue Obamacare’s optional expansion of the Medicaid program, which would extend health coverage to an additional 140,000 uninsured Tennesseans and bring in $1.4 billion in federal funding in the first year.

Eight of Haslam’s fellow Republican leaders have come out in support of this provision of the health care reform law, as partisan opposition to Obamacare’s state-level reforms is finally beginning to give way. But the Tennessee governor is standing firm in his opposition to extending public health insurance to additional low-income Americans. Instead, Haslam will seek to extend coverage to the expanded population by using federal funding to buy private insurance, an alternative to Medicaid expansion that’s enticing a growing number of Republican leaders. The Tennessee governor said he won’t push for expansion until the federal government approves that plan.

Haslam’s announcement comes on the heels of reports about the dire state of Tennessee’s Medicaid program, known as TennCare. Since there are a significant number of low-income Tennessee residents whose annual incomes put them above the cut-off for TennCare coverage, but whose expensive medical bills make them unable to afford to purchase private insurance on their own, the state holds a “health care lottery” twice a year to allow those residents to call in for a special application for TennCare. The phone lines are flooded, and many people are unable to get through. Many of those people would be eligible to gain public health insurance coverage under the Medicaid expansion, and would no longer have to desperately dial a state number in the hopes of winning an elusive lottery to access the care they need.

Despite the fact that Tennessee is a deeply Republican state with a GOP-led legislature, Obamacare’s Medicaid expansion has won some support from business and labor leaders. The state’s largest business organization, the Tennessee Chamber of Commerce & Industry, came out in support of Medicaid expansion earlier this week, explaining that ensuring health coverage for poorer Tennesseans will have a “substantial economic impact benefiting our overall economy.”

Adding to the extensive body of evidence that participating in Obamacare’s optional Medicaid expansion is both smart fiscal policy and the right move for securing poor Americans’ health care, a new Robert Wood Johnson Foundation and Urban Institute study concludes that states refusing to expand Medicaid will leave over 200,000 low-income, uninsured veterans and two-thirds of uninsured veterans’ spouses without access to affordable health coverage.

According to the report, out of America’s 1.3 million uninsured veterans, 40 percent could qualify for expanded Medicaid benefits under Obamacare, but “of the half-million uninsured veterans who would be potentially Medicaid eligible under the ACA, three-quarters—414,000 people—have incomes below 100 percent of FPL and would not qualify for exchange subsidies if their state does not expand Medicaid. Likewise, two-thirds of veterans’ spouses who could qualify for expanded Medicaid under the ACA would not be eligible for exchange subsidies should their state not expand Medicaid.”

That’s bad news considering that the majority of those veterans live in states whose governors have either chosen not to expand Medicaid or have not yet decided whether to expand. That presents a massive burden for veterans — and veterans’ families — who don’t have health insurance, pricing them out of the medical system and forcing them to forgo or delay care due to its associated costs.

And this study doesn’t even take into account the tens of thousands of veterans who have yet to return home from the waning Afghanistan war. Those veterans are mostly young Americans who will be forced to confront the widespread economic inequality, record homelessness, and unprecedented levels of PTSD and suicide that are plaguing veterans of the Iraq and Afghan wars.

Twice a year, Tennessee holds a “health care lottery” that gives some hope to the uninsured residents in the state who can’t afford health coverage. Tennesseans who meet certain requirements — in addition to falling below a certain income threshold, they must be elderly, blind, disabled, or a caretaker of a child who qualifies for Medicaid — may call to request an application for the state’s public health insurance program, known as TennCare.

The lottery is part of TennCare’s “spend down” program, which allows a resident’s income to be calculated after subtracting their medical costs from their total earnings. That means that some Tennesseans who technically earn too much annual income to qualify for public insurance could still be eligible for TennCare if they successfully complete the application process. The New York Times notes that while other states have similar “spend down” initiatives, most don’t limit the lottery enrollment period to a narrow window of call-ins. The unique enrollment process in Tennessee highlights the overwhelming demand for affordable health services, as many low-income Americans fall into a gap between being able to qualify for Medicaid and being able to access private insurance coverage:

State residents who have high medical bills but would not normally qualify for Medicaid, the government health care program for the poor, can call a state phone line and request an application. But the window is tight — the line shuts down after 2,500 calls, typically within an hour — and the demand is so high that it is difficult to get through. [...]

“It’s like the Oklahoma land rush for an hour,” said Russell Overby, a lawyer with the Legal Aid Society in Nashville. “We encourage people to use multiple phones and to dial and dial and dial.”

The phone line opened at 6 p.m. on Thursday for the first time in six months. At 5:58, Ida Gordon of Nashville picked up her cordless phone and started dialing. Ms. Gordon, 63, had qualified for TennCare until her grandson, who had been in her custody, graduated from high school last spring. Now she is uninsured, with crippling arthritis and a few recent trips to the emergency room haunting her.

“I don’t ask for that much,” Ms. Gordon said as she got her first busy signal, hanging up and fruitlessly trying again, and then again. “I just want some insurance.”

If Tennessee Gov. Bill Haslan (R) opted to expand Medicaid under Obamacare, more than 180,000 people would be able to be added to the TennCare rolls by 2019. Obamacare’s Medicaid expansion would extend coverage to low-income Americans whose earnings are above the current cut-offs for public assistance — which would include many of the people like Ida Gordon, who are desperately dialing and redialing in the hopes of winning an elusive health care lottery. Haslan has not yet decided whether Tennessee will accept Obamacare’s optional expansion of the Medicaid program, although he has indicated that he may make his decision sometime this week.

A growing number of GOP governors across the country have begun to concede that expanding Medicaid makes sense for the low-income residents in their states. But many of their fellow Republicans still aren’t willing to cooperate with the health reform law whatsoever — even going so far as to suggest that Obamacare will “degrade” or “destroy” what is already the “best health care system the world has ever known.” As Tennessee’s health care lottery demonstrates, however, the low-income Americans who are resorting to desperate measures to access the care they need may not agree with that assessment.