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November 23, 2014

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Lousy arguments against Medicaid

For now, the big news about Obamacare is the debacle of HealthCare.gov, the Web portal through which Americans are supposed to buy insurance on the new health care exchanges. For now, at least, HealthCare.gov isn’t working for many users.

It’s important to realize, however, that this botch has nothing to do with the law’s substance, and will get fixed. After all, a number of states have successfully opened their own exchanges, doing for their residents exactly what the federal system is supposed to do everywhere else. Connecticut’s exchange is working fine, as is Kentucky’s. New York, after some early problems, seems to be getting there. So, a bit more slowly, does California.

In other words, the technical problems, while infuriating — heads should roll — will not, in the end, be the big story. The real threat remains the effort of conservative groups to sabotage reform, especially by blocking the expansion of Medicaid. This effort relies heavily on lobbying, lavishly bankrolled by the usual suspects, including the omnipresent Koch brothers. But it’s not just money: the right has also rolled out some really lousy arguments.

And I don’t just mean lousy as in “bad”; I also mean it in the original sense, “infested with lice.”

Before I get there, a word about something that, as far as we can tell, isn’t happening. Remember “rate shock”? A few months ago it was all the rage in right-wing circles, with supposed experts claiming that Americans were about to face huge premium increases.

It quickly became clear, however, that what these alleged experts were doing was comparing apples and oranges — and as Ezra Klein of The Washington Post pointed out, oranges that, in many cases, you can’t even buy. Specifically, they were comparing the premiums young, healthy men were paying before reform with the premiums everyone — including those who previously couldn’t get insurance because of pre-existing conditions — will pay under the new system. Oh, and they also weren’t taking into account the subsidies many Americans will receive, reducing their costs.

Now people are signing up for policies on state exchanges and, to a limited extent, on the federal exchange. Where are the cries of rate shock? Anecdotal evidence, which is all we have so far, says that people are by and large happily surprised by the low cost of their insurance. It was telling that when Fox News eagerly interviewed some middle-class Americans who said they had been hurt by the Affordable Care Act, it turned out that none of their guests had actually checked out their new options — they just knew health reform was terrible because Fox News told them so.

Now, about those lousy Medicaid arguments: Last year’s Supreme Court decision upholding the Affordable Care Act did strike down one provision, the one that would have forced all states to accept an expansion of Medicaid, the already-existing program of health insurance for the poor. States are now free to reject that expansion. Yet how can states justify turning down a federal offer to insure thousands of their citizens, one that would cost them nothing in the first year and only trivial amounts later? Sheer spite — the desire to sabotage anything with President Barack Obama’s name on it — is the real reason, but doesn’t sound too good. So they need intellectual cover.

Enter the same experts, more or less, who warned about rate shock, to declare that Medicaid actually hurts its recipients. Their evidence? Medicaid patients tend to be sicker than the uninsured, and slower to recover from surgery.

OK, you know what to do: Google “spurious correlation health.” You are immediately led to the tale of certain Pacific islanders who long believed that having lice made you healthy, because they observed that people with lice were, typically, healthier than those without. They were, of course, mixing up cause and effect: lice tend to infest the healthy, so they were a consequence, not a cause, of good health.

The application to Medicaid should be obvious. Sick people are likely to have low incomes; more generally, low-income Americans who qualify for Medicaid just tend in general to have poor health. So pointing to a correlation between Medicaid and poor health as evidence that Medicaid actually hurts its recipients is as foolish as claiming that lice make you healthy. It is, as I said, a lousy argument.

And the reliance on such arguments is itself deeply revealing, because it illustrates the right’s intellectual decline. I mean, this is the best argument their so-called experts can come up with for their policy priorities?

Meanwhile, many states are still planning to reject the Medicaid expansion, denying essential health care to millions of needy Americans. And they have no good excuse for this act of cruelty.

Paul Krugman is a columnist for The New York Times.

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