ACA exchange plans cost near-poor more than Medicaid

The Commonwealth Fund just released an interesting brief regarding the effects of failing to expand Medicaid on the health care costs of people between 100 and 138 percent of the poverty line.

Yes, that sounds about as exciting as watching paint dry, loyal readers (both of you) but it’s important – so wake up, dammit!

Here’s the score:  the Affordable Care Act expands Medicaid to cover everyone under 138 percent of the poverty line. The problem is that 19 states – generally dominated by Republicans – have

refused to expand their Medicaid programs. This poor public policy has created a “Medicaid gap” consisting of people who are too rich to qualify for legacy Medicaid (in Texas, for example, parents earning more than 15 percent of the poverty line – about $2,400 a year for a family of 2 – don’t qualify) but too poor to qualify for subsidies on the health insurance exchanges, which are available to households earning between 100 and 400 percent of the poverty line.

The 3.2 million people in this gap have no functional access to insurance, since there’s no way a person making, say, $10,000 a year can afford several hundred dollars a month in health insurance premiums.

People earning between 100 and 138 percent of the poverty level in non-expansion states are considerably better off though, because they qualify for both premium subsidies and cost-sharing subsidies for exchange plans. The indispensable Charles Gaba has estimated this group at roughly 1.9 million people.

But do the exchange plans stack up favorably with the generosity of Medicaid for poor people?

The good scholars over at Commonwealth Fund set out to find out. And their general answer is “no.”

Follow me below for more details.

Expanding the Umbrella: Medicaid Expansion 2015 Review and New Year's Preview

With 2016 right around the corner, and several new governors moving into office, it's as good of time as any to take stock of where the Medicaid expansion has gone and the prospects for progress in the new year.  Despite massive Democratic setbacks at the state level in the 2014 midterm elections, Medicaid expansion fared reasonably well in 2015, and 2016 posts several opportunities for new states to expand as well, as well as one at risk of backsliding.

First, we visit the ghosts of Medicaid expansion past:

As Chart I shows,  the ACA Medicaid expansion has proceeded at a similar overall pace to the original Medicaid take-up in the late 1960s, though the holdouts to Obamacare are likely to offer stiffer resistance than the late adopters of the initial program.

Democratic defeats in the 2014 elections likely prevented expansions in Maine and possibly Florida, and may have influenced resistance to expansion plans in several other states, including Tennessee, Utah and Wyoming. However, Four new states joined the expansion -- Indiana, Pennsylvania, Alaska, and Montana -- which increases the number of states fully expanding Medicaid from 26 to 30. 

Head below the fold for state-by-state analysis and a peak at 2016.

How do we use bikeshare in the Sun Belt?

The Kinder Institute at Rice University has an interesting report out comparing four Bike-Share Systems in four "Sun Belt" cities.  Three are in Texas (Austin, Houston, Fort Worth), while the other is in Colorado (Denver).  The report's central idea is to get a snapshot of bike share in newer cities with lower density and planning optimized for the automobile -- in contrast to the old urban areas in the Northeast with high density.

The study, which covers the first five months of 2015, notes that most kiosks and most trips are still of the two-way weekday variety (i.e. from one-Kiosk to another), indicating that most users use the system for work trips.  However, there is a greater percentage of users in Houston and Fort Worth -- especially Houston -- who use the systems for round trips (i.e. they start and end at the same Kiosk). I'd be interested to see how this compares with bike share systems in older, denser cities.

The study is a good first stab and thinking about how we use bike share in newer cities, but I do have several additional points to make here, including a criticism or two. 

First it's interesting to note that the broad pattern of trips in these Sunbelt cities still is two-way weekday trips, which indicates that many residents here use the program for similar purposes to those in older cities -- though the report doesn't explicitly compare the two.

Second, I think that the report misses a rather obvious explanation for the differences in trip types between the cities. The authors do suggest several useful variables to explain the differences in usage across kiosks and cities. For example, they note that cities with greater numbers of kiosks have more two-way work trips. Also, the kiosks with more round-trips tend to be located near bike paths or in large parks. Also, Houston allows for a full hour of use before additional surcharges kick in, unlike the traditional pay system which gives a free half hour to the first members.

However, the report misses the idea of density.  Denver's and Austin's systems seem at first glance to be more closely spaced in a tight network, facilitating two-way commuter or errand trips. In contrast Houston and Fort Worth's systems are more spread out, limiting the utility of the system and leading to people treating it like a bike rental than bike share. They don't have any measurements on density, which would be interesting to see as well (maybe a median distance between adjacent kiosks, or a distribution of distances would be a good measure here....)

Density of the network is also rather valuable to total usage, as a National Association of City Transportation Professionals study has noted. So as Houston looks to expand this year, while I hope officials expand the scope of the bike share (please, please come to Rice Village!), I also hope they reinforce its density in its existing footprint (more stations in the Museum District!). This will expand its utility as a short-distance commuting tool.

And it goes without saying that expanding the bicycle infrastructure on the ground (more and better bicycle lanes please...) will help bring more cyclists on to the roads and keep cars moving at more reasonable (and safer) speeds.

But with this gripe aside, the report is a nice initial foray into how bike share works, and has nice nuts-and-bolts data on the use of each kiosk in all the cities and some good basic visualizations of usage in each city's network.

The invaluable Charles Kuffner, as always, has a summary and extensive analysis of a Houston Chronicle article on the subject.  He also makes the trenchant point that while knowing how people use bike share is useful, the fact that they are using it widely is the most important point.

Amen to that.

Union contracts, what are they good for?

Last week, Erik Loomis posted a summary of an article about the ongoing pilots' union negotiations with Southwest.  Loomis' point (and the excellent article he links to) are that union negotiations are about more than money -- they are also about the conditions under which employees work.  In this case, pilots voted down a proposed contract that offered them a large raise in part because Southwest demanded far more flexibility on duty hours to match other airlines  (which had managed to force those concessions from bankruptcy judges).

With the constant refrain we hear about unions being all about grabbing money, this idea of the employment environment is extremely important. I would also add that rules about firing and hiring are very important as well. My old union at the University of Michigan just settled (and essentially won) a grievance filed by a Graduate Student Instructor named Alex Chen who was offered and accepted a job in the bargaining unit, before having that offer yanked by her supervisor for spurious reasons. 

Of course, Chen lost her health insurance and tuition waiver in addition to her salary. This situation is deadly to a graduate student, who probably would have to drop out of school facing a tuition bill of more than $10,000. I've known several students in situations like this; and the psychological stress they face is extreme.

Chen reached out to the union and found out that not only did contract language back her position, but that she also scores of fellow members willing to protest on her behalf.  That article, which details what happened in the meeting, contains several fabulous anecdotes about a department program chair behaving like a stubborn child who has been caught lying about doing her homework.

An interview with Chen outlining her particular situation is here.

Anyhow, I highly recommend Loomis' post -- and the excellent comment thread, which features a really good discussion of the nuts and bolts of work rules in a contract led by a freight pilot (Major Kong) who is often found in the comment threads of progressive blogs. The thread is doubly worthwhile because it brings in information from the union and not just from Southwest, as well as discussing how issues like codeshare and subcontracts with regional airlines can undercut airline unions.

And remember -- work rules and hiring practices are just as important as wages.

With Bel Edwards win, Louisiana set to expand Medicaid

A quiet legislative maneuver from last Spring combined with an unexpected triumph of Democrat John Bel Edwards in the governor's race makes it nearly certain the Louisiana will become the 31st state -- and second in the former confederacy --  to expand Medicaid.

On Saturday, Edwards, who strongly favors expansion, easily defeated sitting U.S Sen. David Vitter in Louisiana's gubernatorial run-off election (after throwing this haymaker on the airwaves). Edwards' replacement of Bobby Jindal in itself removes a massive obstacle to the Medicaid expansion, as Jindal is an implacable (and inexplicable) foe of covering 242,000 uninsured Louisianans.

However, the state legislative majorities remain firmly in GOP hands in Louisiana. This phenomenon has stalled governors who have wanted to accept the expansion: just ask Jay Nixon in Missouri, Terry McAuliffe in Virginia and (until recently) Steve Bullock in Montana.

But the good news is that the legislature in Louisiana already has acted. Well, sort of. The legislature has rejected multiple bills expanding Medicaid in 2013, 2014 and 2015. However, in 2015 both houses passed a joint resolution laying out circumstances under which the state can expand Medicaid. The resolution creates a mechanism under which -- if a new governor assents -- the department of health and hospitals will set a fee on hospital systems to fund any state portion of the Medicaid expansion. Hospitals will likely be fine with this, as the bill exempts the smallest providers and in any case accepting federal Medicaid dollars will pump a much greater amount of funding back into the system.

In short, the legislature isn't exactly pushing for an expansion, but it is devolving its power to set up a mechanism under which a governor can chose to take it. That's exactly the opposite of what Texas did in 2013, when it took away the governor's power to accept the expansion in order to make it less likely that the state would take it.

So in any case, at least we're stumbling forward toward doing the right thing -- after we've tried everything else, of course, but I'll take it.  

Finally, note that this happening is further evidence of two important points.

First, Republican resistance to the Obamacare remains strong and widespread, but continues to slowly erode at the state level.

Second, quite simply is that elections still matter. Each of the four major contenders in the Louisiana gubernatorial race, including the three Republicans, expressed openness to expanding Medicaid. However, Edwards was the most consistent and strident supporter of expansion and is the least likely to impose conditions on expansion that would hurt recipients.

How much would expanding Medicaid help in states that haven’t accepted the expansion?

Perhaps the single biggest story about the implementation of the Affordable Care Act has been the battle in states deciding whether to accept the Medicaid Expansion. The expansion is perhaps the single most important tool in the ACA’s coverage expansion tool kit. It takes 50 state-based single payer systems and drastically expands eligibility for them, which is the single largest progressive victory in politics since the Great Society. Other important Medicaid reforms drastically streamline the application procedures and eliminated asset tests to draw out formerly eligible people who might have gotten tangled up in the system or not bothered applying because the state made you apply in person on Tuesday between the hours of 2:30 p.m. and 3:04 p.m.

However, the expansion is not some magical talisman that instantly enrolls all eligible individuals. Some people will remain ignorant of the program despite the best outreach efforts, while other will not enroll for any variety of reasons. And more to the point, 24 states hadn’t fully taken advantage of the Medicaid expansion by the beginning of 2015. Pennsylvania, Indiana, Montana and Alaska have all signed on this year, leaving 20 holdouts (half of whom were in the former Confederacy – but I digress).

The cool thing that we have some real data of how ACA has actually performed on the ground over the last two years, we make some interesting dynamic projections of what would have happened had some states accepted the Medicaid, instead of simply discussing the number of people who would be eligible for help under the expansion.

I mean, heck, this Charles Gaba fellow has been counting the people who actually signed up for coverage for two years, I might as well take one shot at figuring out who would have signed up if they could have. 

To accomplish that, follow me below the fold, where I build a simple interactive regression model to project the reduction in the uninsured population in states that haven’t expanded Medicaid. Don’t worry; I’ll label the scary part where I work through the model so you can skip the simple summary where I discuss the results in plain English (but you really should read the model section, it’s rather of important and it makes fun of Bobby Jindal).  

ACA reduces uninsured in Texas, but would do more if state expanded Medicaid

Shockingly (not really), failure to expand Medicaid continues to cost poor Texans access to health insurance.

The Baker Institute at Rice University the Episcopal Health Foundation have released their latest issue brief on the latest results of the Health Reform Monitoring Survey, a quarterly survey which tracks the effects of the Affordable Care Act on individuals.  The Institute and  the Foundation implement the survey for Texas.

This report contains absolutely no surprises for anyone with more than three functioning brain cells and who hasn’t been living under a rock for the last five years.

First, the good news: The percentage of uninsured working-age adults (ages 18-64) estimated by the survey declined by nearly one third, from nearly 25 percent to 17 percent between September 2013 and March 2015. Most encouragingly, Hispanics – though still the higher proportion of uninsured in Texas – had the largest decline, with a drop of 38 percent.

This indicates that the health exchange model, supported by federal subsidies, is helping a large number of uninsured individuals get coverage.

The bad news of course, is that poor people who fall into “Medicaid gap” – those who earn income less than 100 percent of the poverty line necessary to obtain subsidies on the exchange, but higher than current Texas cutoffs for Medicaid -- are still left out in the cold.  The memo notes that respondents under 138 percent of the poverty line have increased from roughly 63 percent to 67 percent of those uninsured in Texas. This change in the two surveys isn’t statistically distinct from zero, but almost surely understates the impact of the state’s failure to expand Medicaid, because individuals between 100-138 percent of the poverty line qualify for subsidies.

Two other nuggets in the report are of interest.  First, the potential tax penalty for health insurance, also known as the individual mandate -- appears to have some effect on driving the uninsured to seek insurance. More than half (53 percent) of uninsured respondents say that the prospect of a fine for not purchasing insurance is “somewhat” or “very” important to them. (Note that the IRS is waiving the fine for households that fall into the “Medicaid gap.”

Finally, uninsured respondents overwhelming say that they can’t purchase insurance because they can’t afford it (57 percent) instead of because they don’t want it (17 percent). That’s useful because it undermines (again) the talking point that uninsured people are satisfied in their current state and that the government should just butt out.

To sum up then: Texans generally want health insurance, the ACA is effective in helping them get insurance, and the ACA would help a lot more Texans get insurance if the state were to expand Medicaid. Absolutely all these things were predicted by proponents of Obamacare.

Obama judicial appointments slow to a crawl

Much of the focus in the Senate right now is justifiably on the GOP majority's slow-walking Loretta Lynch's confirmation vote for attorney general on the Senate floor. 

But what's getting a lot less attention is the predictable lack of traction that President Obama's judicial nominations are getting.

The Senate has not confirmed a single judicial appointment this year in three months of work.

Contrast that with the first three months of 2014, the Democratic majority confirmed three circuit court judges and 16 district court judges.

In the first three months  of 2007, the incoming Democratic majority confirmed two of George Bush's circuit court nominees and 13 district court nominees.

Four rather uncontroversial district court nominations are waiting for a floor vote --three in Texas and one in Utah -- all which easily cleared the Judiciary committee in February. They'll get through the Senate eventually, but somehow I don't think Mitch McConnell has them as a priority.

Just another reminder that elections matter.

Obamacare is about People, not States

On January 30, Ezra Klein posted an insightful Vox piece about one of the great ironies of the Affordable Care Act.  After a lot of thought of my own, however, I don’t think it’s much of an irony at all. 

Klein’s analysis noted that the original ACA – supported heavily by Democrats – featured a massive redistribution of wealth from Blue States to Red States.  The people helped by Obamacare’s Medicaid expansion and exchange subsidies were disproportionately concentrated in the states of the ex-Confederacy that had low-wage economies with skimpy existing Medicaid programs. (An old joke in Mississippi claims that you have to be legally dead to qualify).

The irony that Klein points out has been that Republicans are fighting tooth and nail to turn the ACA into a program that drains money from Red states and transfers it to Blue States. When the Supreme Court held that the Medicaid Expansion had to be optional for states, many states dominated by Republicans declined the expansion while Blue States snapped it up, shifting the benefits flow from Red States to Blue States If the Supremes decide the case of King vs. Burwell in favor of the forces of darkness, it will declare subsidies on exchange marketplaces illegal – but only in the states on the federal exchange, which of course are disproportionately Red States. As a result, higher earners in Texas will be sending their increased Medicare taxes to poor and working-class people in states like New York and California while their own states lose out.

It’s an interesting puzzle, but I think it can be explained quite easily – at least on the liberal side of the equation – by changing our unit of analysis. Klein looks at states, but I think it makes more sense to look at people to explain this paradox. On some issues, perhaps it makes sense to look at issues as state vs. state.  If a major manufacturer decides to leave one state and move to a second, for example then pretty clearly the second state is better off relative to the first. Politicians will act accordingly and line up state against state.  

But the motivating purpose behind the Affordable Care Act wasn’t about New York vs. Texas, it was about 48 million people in the United States who didn’t have health insurance. Ohio Senator Sherrod Brown didn’t refuse to take federal health insurance because Florida got more Medicaid dollars than Ohio, but rather in solidarity with millions of Floridians and Ohioans who didn’t have access to health care at all. If Mississippi took $14.5 billion in federal money over the next decade to expand Medicaid, I wouldn’t be mad that that money wasn’t going to Pennsylvania, my latest state of residence; I’d be celebrating because 169,000 of my fellow citizens got access to health care.

On the flip side, the logic is perhaps more difficult to explain for a Red State GOP governor like Rick Perry or Mississippi’s Phil Bryant. There’s the potential that they just don’t understand it. Perry recently suggested that millions of Texans liked not having insurance, which may represent a weak dodge or actual ignorance of reality. But there’s also the possibility it’s about people for them too – specifically “those people” who are poor and likely have a darker hue of skin and are viewed as undeserving of federal benefits. Politicians used to be able to wrangle earmarks and pork for their state , which reduces the role of ideology, but ideological sorting and polarization has been getting stronger over the last 40 years. As a result, politicians who rely on bringing home federal dollars to get votes find themselves facing tough primaries – like the one Thad Cochran barely survived in Mississippi in 2014.

We can solve Klein’s puzzle then by re-imagining the pieces. It’ not about cash flows to states, it’s about people – and whether a state official’s ideological blinkers permit those without access to health care to be seen as human beings deserving of compassion or dignity.

Boggs hearings represent mere hiccup -- Obama judge picks continue confirmation surge

There’s been a lot of frustration among Progressives over Republican senators continuing to block Obama judicial picks in committee thanks to the blue slip method.  The latest manifestation of the frustration comes with the nomination of Michael Boggs, a Republican-backed candidate nominated as part of a deal to fill several slots on federal bench in Georgia (In return for nominating Boggs and two other district appointments, Georgia’s Republican Senators agreed to allow the nomination of Jill Pryor to move forward for the 11th Circuit Court seat and Leigh Martin May for a district judge seat.)

Progressives' frustration is understandable – as a state judge and legislator Boggs has defended voter identification laws, displaying the Confederate flag and opposed gay rights. However, Democrats should also keep their eyes on the forest through the trees: with the elimination of the filibuster for most executive nominations last November, judicial confirmations have drastically increased.

How much?  In 2014, the Senate has confirmed 40 judges thus far – 33 in the district courts and seven in the appellate courts. During the first five years of Obama’s presidency, the previous high number of judges confirmed through the end of May was 24 (in 2011 and 2012).  That translates into an increase of 67 percent in the number of judicial confirmations. Oh – and we’ve still got another week of Senate business to go in May. 

In addition, the vacancy rate is also starting to decline noticeably on the federal bench.  At the beginning of December, just after the Senate eliminated the filibuster, there were 86 vacancies on the district and circuit courts. That number increased on February 1 to 96 openings – likely because GOP obstruction forced Obama to resubmit every nomination, forcing a fresh round of committee hearings. However, by the beginning of March, the number of vacancies was beginning to fall and has continued to decline ever since. By May 20, the number of vacancies had declined to 67, a decrease of 30 percent from its February high (See figure).

Again, this happening doesn’t mean that everything is rosy.  In some states dominated by conservatives, the process is slow (like in Georgia) or seems entirely hopeless, like in Texas (though the Fifth Circuit court will pick up Texan Greg Costa today).  

And would some one give Jennifer Prescod May-Parker of North Carolina a commission already?

However, even in some conservative states there has been progress.  Four nominees from Florida have cleared committee and await final confirmation after months of obstruction from Senator Marco Rubio. More importantly, Arizona has a functioning district court for the first time in several years as six  nominees received confirmation last week – including Rosemary Marquez, who was first nominated in 2011 and blocked by Arizona's senatorial delegation, and Diane Humetewa, the first Native American woman to become a federal judge.

The point is that progressives are right to be frustrated by continuing blocking of some nominations,  however, we should keep it in the back of our minds that nominations are flowing much more quickly now than they were a year ago.

Raise the minimum wage to reduce the Medicaid gap

Aaron Carroll of at The Incidental Economist (a must-read blog for those with interest in health care policy) has a really thoughtful post up on the people who fall into the Medicaid gap in states that aren't choosing to expand Medicaid at the Academy Health Blog. These people are in a bind; they're too rich to be covered under most of these states' existing Medicaid plans, but they fall below the poverty line, and aren't eligible for subsidies on the health exchanges. In describing this population, Carrroll writes a paragraph that really got me thinking:

It’s worth considering, though, that the majority of people in the coverage gap are working poor who, ironically, make too little to be helped out by the government. If they made just a bit more, they might qualify for insurance that is so subsidized that it is almost free. But because of the coverage gap, the people with the fewest resources get less help (none)  than those who have a bit more money. (Italics mine)

If only the working poor made just a bit more money, we could lift hundreds of thousands of them above the poverty line and get them eligible for subsidies that would massively cut their monthly premiums and limit their out-of-pocket expenses. Hmm... what could we possibly do to get the working poor some more income?

Oh I don't know, it's crazy, but maybe we could just raise the minimum wage.

Some minimum wage comparisons Or "Yes, we can most certainly afford to raise the minimum wage"

So it appears one of the next big issues that's coming to a head is a debate over raising the national minimum wage. New Jersey raised its minimum wage and linked it to inflation during the last election, while the town of SecTac in Washington State raised its minimum wage to $15 an hour. Washington D.C. and two neighboring counties just voted to raise their wage to $11.50 an hour over the next several years, while California has voted to jump its minimum to $10 over two years.

Texas Republican Joe Barton, naturally, wants to go the other way.

Right now, the current minimum wage of $7.25 is worth about what it was in 1950 in inflation-adjusted dollars. I show the fluctuation of the minimum wage's value in this fairly well-known chart (figure I) that I reproduced with data from the Bureau of Labor Statistics.

What should we raise it to? Thinking about it's relationship to the poverty line is a good place to start, (though the limitations of the poverty line makes it a bad place to finish.) 

The poverty line for a single parent raising one child is $15,510 for 2013 and for a family of three (a single parent with two children) it's $19,530. For a full-time job at minimum wage to earn enough to lift a family of two above the poverty line, it would have to pay $7.76 an hour-- a raise of about 7 percent from the current wage. To lift a family of three with one worker out of poverty, it would need to be $9.77 -- a raise of about 35 percent.

Of course, that's assuming a full-time job. Many minimum wage jobs in fast-food and retail require lots of flexibility and limited hours (hey, if we gave workers over 28 hours a week, they'd be full time and we'd have to provide health benefits and we couldn't have that!). So let's assume a 25-hour work week, which is more typical at a minimum-wage service job. Keeping a single-parent family of two above the poverty line now requires $12.41 and hour, while a family of three requires $15.63; increases of 71 and 115 percent, respectively.

For historical context,  the minimum wage peaked at a value of $10.74 in 2012 dollars in 1968, which would be a raise of about 48 percent. If the wage had kept up with gains in worker productivity, we'd be looking at a minimum wage of $17.65 an hour, which is an increase of 143 percent. 

I stack all these possible wage gains in Figure II below:

We can debate how high the minimum wage should be, but America needs a raise, and their bosses can afford it. Based on the figures above, D.C's $11.50 over the next three years is easily justifiable, and fast food workers arguing for $15 an hour have a good case to make. Indexing to inflation is a must and future increases arguably should also account for productivity gains above the rate of inflation.

From Consent to Advice -- other possible avenues to block judges in the Senate

Yesterday, we all crawled out from our radiation shelters to behold the charred remains of the Senate landscape. You see, Harry "Major Kong" Reid engaged the nuclear option last Thursday, blowing up chamber procedure and changing to require only a majority vote to end debate on executive and non-Supreme Court judicial nominations.

So now what? Over the short term, the confirmations should flow fairly quickly. There are currently four appeals (including the three D.C. circuit nominees) and 13 district court nominations that have passed through the Senate Judiciary Committee and are awaiting floor action. They should fly through in a jiffy in December.

Behind that immediate flurry, the picture gets a bit murkier. There are currently 93 vacancies on the federal bench --  18 on the appellate level and 75 at the district level. Getting the 17 easy confirmations out of the way leaves 76 slots (14 appellate and 62 district). Of these Obama has nominees for six appellate and 30 district vacancies.

There are two ways Republicans can slow down or block nominations to these vacant slots.

Medicaid expansion rejection silver linings playbook: Deficit reduction

One of the biggest shortcomings of the Affordable Care Act (the post-Supreme-Court-decision-haircut version) is that it makes the state Medicaid expansions optional for states. As of this writing, 25 states have not signed on to the expansion, leaving millions of Americans below the poverty line without the ability to afford health insurance.

One piece of good news is the woodwork effect is real. Streamlining of the Medicaid enrollment process across all states will help many people who are currently eligible for Medicaid but never figured out how to apply will enroll, even in states refusing the expansion.

But there might be another silver lining to states refusing to expand Medicaid: deficit reduction.

First, a disclaimer:  My first-choice policy preference is to expand Medicaid. Actually, that's my second and third choices as well. And when it comes to prioritizing deficit reduction during times of high unemployment and recession, I side with the great Charlie Pierce:

Now I have only one opinion on economics — Fk The Deficit. People Got No Jobs. People Got No Money —

However, all else equal, I would rather to see a lower deficit than a higher deficit and a lower public debt than a higher one. (If nothing else, it gives the Fix the Debt crowd less leverage when they argue for gutting the welfare state.) And I was thinking that since the Congressional Budget Office projects that the Affordable Care Act will slightly cut the deficit over time, what happens if a significant number of states reject the Medicaid expansion, which makes up about half of the spending for the ACA?

To answer this question, I looked up projected state-by-state Medicaid spending figures from this 2012 Kaiser Foundation study. Using a spreadsheet, I added up the federal fund the 25 states that haven't indicated they will be accepting the expansion don't accept it over the next nine years.

 

That number comes out to $437 billion ($78 billion from Texas alone). That's a lot of money.

 

In fact, nominally, it's about of $48.5 billion a year, which is roughly 7.5 percent of the 2013 deficit. That overstates the impact a bit, because the numbers aren't strictly comparable, because A.) they are nominal, not year-of expenditure dollars (i.e. this doesn't adjust for inflation) and B.) Medicaid expenditures will be larger in later years as health costs grow -- though the federal share of spending will drop back to 90 percent by 2018.

Again, I deplore cutting the deficit on the backs of the poor. But until state governors start wising up, at least we're not blowing that Medicaid money on tax cuts for hedge fund managers. In fact, we're taxing hedge fund managers -- about 25 percent of the revenue for the ACA comes from increasing payroll taxes on wealthy incomes -- including investment income.

So keep pushing to expand Medicaid in states that haven't yet. Political pressure from combined with financial realities likely will push many of the recalcitrant states into the fold over the next few years. However, in every state we don't succeed, take a bit of solace in the fact that we raised taxes on the rich to cut the deficit. 

That's almost as French as universal access to health care.