Depraved Indifference

The senseless cruelty of rejecting Medicaid expansion

Every individual who holds significant political office has the power and burden of making life or death decisions (so, you’re off the hook if you’re the mayor of Wasilla, Alaska :)). Politics involves tradeoffs. When you allocate resources here, you draw them from there. In favoring some groups, policies and priorities, you are disfavoring others. If you agreed to a certain level of health funding, the difference between what you settled for and the higher amount you might have fought for can be statistically inferred to result in increased mortality. While having inescapable real world consequences, these choices typically exist in a moral gray zone. Maybe you wanted to do more, but were blocked from doing so. Maybe other urgent priorities required your attention. And you have to make these choices in the face of the ultimately finite resources available to you. In any event, there is no such thing as a perfectly crafted policy that can enhance and optimize the well-being of every single potentially affected person. We are fallen.

In some cases, though, the tradeoffs are so lopsided in favor of basic well-being that choosing otherwise isn’t just the normal, inescapable to and fro of politics. Choosing otherwise amounts instead to calloused, pointless cruelty that deserves to be called senseless killing.

This is how we ought to be thinking about the ongoing obstruction of Republican leaders in a dozen states to accepting Medicaid expansion.

Some historical context. When President Obama signed into law the Affordable Care Act (ACA) in 2010, it included a provision requiring every state to expand its existing Medicaid program or to pay a substantial penalty. At the time, it was estimated this provision would extend health insurance coverage to some sixteen million Americans, including many older Americans who were not yet Medicare-eligible. It would also provide funding to fortify the program more broadly, including to impoverished families with children in which the parents could not otherwise afford adequate health care. The ACA also assumed most of the cost of this expanded coverage. Under the law, the federal government would pay 100% of the cost of expansion for the first few years, then 95% and, eventually (as of 2020), 90%.

But when Medicaid expansion went into effect in 2014, only about half the states were participating. Why? Because, in 2012, a legal challenge to Obamacare reached the Supreme Court. The ACA survived that challenge, but the Court ruled that the ACA could not mandate expansion. In subsequent years, some initially-resistant states reversed themselves, including several states that put the issue on the ballot, where expansion is undefeated.¹ That leaves us with the current dozen holdout states.

In the American political context, expansion was, and is, about as close to a win-win for the states as one can find in a major public policy. It would substantially increase access to care for a state’s residents. In Alabama, for example, up to 340,000 residents who are currently uninsured would have coverage. That would represent a roughly 43% reduction in Alabama’s uninsured rate, making it the state that would most benefit from expansion. In North Carolina, my state, as many as 600,000 currently uninsured residents would gain coverage.² Since 2014, even with the dozen obstructing states, close to nineteen million additional Americans are now covered under Medicaid.

From the beginning, recalcitrant Republican leaders have argued that expansion is too expensive. That’s bullshit. Under the ACA, the federal government would, as previously noted, shoulder most of the costs. According to a study by the University of Alabama Birmingham Medical School, Alabama decided to forego an estimated $12 billion in federal money through 2020, because of its obstruction. It’s leaving about $2 billion on the table in 2022 alone. That dwarfs the roughly $200 million a year expansion would impose in direct costs. North Carolina is punting away an estimated $6 billion in 2022, many times what it would cost to expand Medicaid. And that leaves aside the fact that expansion would also be a substantial job creator (because of increased utilization of health care services) and yield other savings. The result is that, in terms of direct budgetary impact alone, states like Alabama and North Carolina would probably not only break even, but be better off.

Most fundamentally, expansion saves lives. One landmark study, focusing on the impact of Medicaid expansion just on people aged 55-64, found that some 19,000 lives were saved between 2014-2017 in states that expanded Medicaid. Conversely, in states that didn’t, there were an estimated 15,000-plus premature deaths. Other studies yield similar results. Indeed, all credible evidence points to large decreases in mortality as a result of expansion.

But let me add some humanity to this rant.

A couple of years ago, the New Yorker’s Eyal Press wrote a long article about the impact of Alabama’s refusal to expand Medicaid on women like Tonya Carter. Carter, 48 at the time, was a divorced mother of four. She’d been earning eight dollars an hour as a home health care worker. Alabama, along with Texas, has the most miserly Medicaid eligibility requirements in the country. In 2020, in order for a parent in a family of four to be eligible, they had to earn less than $390 a month, or 18% of the federal poverty line. Carter couldn’t afford insurance and hadn’t been to a doctor in years. After suffering from increasingly acute pain in her back, Carter finally sought medical care. Once she did, in 2019, she was informed that she had stage IV-B cervical cancer. She was terminal (Carter died in 2021, a year after publication of the story). Press profiled a number of other women who were too poor to have access to health care and, only after experiencing escalating and ultimately blinding pain, discovered that they were suffering from a similar fate.

Cervical cancer is regarded as one of the more treatable kinds and for women of means, it is. But it still claims an estimated four thousand victims a year in the United States, mostly among the poor. A combination of limited access to providers and inadequate information about screenings compound the problem. And like other poorer states, Alabama has seen a rash of rural hospital closures in recent years, limiting care options in some the poorest areas of the state. Indeed, one particularly cruel and infuriating reality of American federalism is that the poorest states tend to be the most punitive. Press noted that the eight states in the country with the highest number of rural hospital closures in recent years had each refused expansion.

When Kay Ivey became governor of Alabama in 2017, she helped scuttle proposals under which Alabama might agree to expansion. Indeed, she tried to make Alabama’s especially harsh existing eligibility rules even more so, though that effort was ultimately abandoned. In 2019, as Press wrote, “during a routine medical exam—the kind of checkup that women without insurance usually go without—a doctor discovered a small malignancy in [Ivey’s] lung. Fortunately for her, the cancer was detected early, and treated immediately…at a state-of-the-art oncology center in Montgomery. In January, scans revealed that Ivey was cancer-free. ‘I am profoundly grateful for this good news,” she announced, thanking God, her “dedicated team of physicians,” and “the good people of our great state.’” Good for her. If only doctors had detected a conscience alongside the cancer.

If you want to be polite about it, you could say that Governor Ivey and her ilk, despite little downside, oppose accepting the federal funds that would reduce mortality in her state. Or you could simply say this “pro-life” governor - along with her allies - is killing people, for no good reason.

1. These are all, by definition, in states that a Republican governor or legislature, or both, blocked expansion, since Democratic-controlled states never opposed it.

2. North Carolina’s Democratic Governor, Roy Cooper, has been fighting with the GOP-controlled legislature over this issue since he took office in 2017. Indeed, North Carolina had no approved budget for two years after Cooper vetoed GOP-produced budgets because they did *not* include provisions for expanding Medicaid. GOP leaders eventually agreed to “study” the issue, which led Cooper to sign the 2021 budget. That’s where things stand as of this writing.