Medicare plans on the rocks

The debate over the expansion of Medicaid, now raging in many states, illustrates the dangers of moving too quickly on some healthcare reforms linked to the Affordable Care Act. Poll after poll in states embroiled in controversial expansion efforts show that public opinion is sharply split over most all the plans for adding to the Medicaid rolls, even if the federal government pays the bills initially. Granted, the battle is interesting with some surprising subtexts, including expansionary support by Republican governors like Arizona’s Jan Brewer, Florida’s Rick Scott and Ohio’s John Kasich. And there is the vigorous support from institutional Republicans, such as state Chambers of Commerce and hospital associations. But despite that remarkable across-the-aisle advocacy, the support just isn’t there for expansion in most states in play, primarily because Republicans aren’t buying in.

What’s the problem? First, I think that Medicaid expansion is perceived as a potentially disruptive and risky “solution” to a problem that just doesn’t exist in the minds of most voters. My own polls on the topic, recently taken in Ohio and Michigan, demonstrate that most people don’t believe that there is a genuine healthcare crisis in their states. And, to boot, most people are happy with the healthcare plan they have now, even if it’s self-funded. So if people don’t believe there’s a crisis, and are happy with their own plight, why would they risk approving a plan that potentially could create a new crisis for taxpayers? Healthcare providers like hospitals will argue that there is a genuine crisis, of course. But they tried skipping the step of educating and persuading the public to accept their story; they went the paid-lobbyist route of policy making, and now they are hitting the brick wall of polling. 

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Even if the hospitals circled back and tried to bring the public along with their expansion plans, they are going to face some tough issues. For one, there are wide variations in the numbers of potential beneficiaries. In some states there are three or four estimates of the number of new Medicaid recipients that would be enrolled under relaxed guidelines. These estimates all come from ostensibly reliable sources, but they cannot all be true. So reformers want voters to endorse a plan in which the total costs are at best variable and at worst unknown. In these hardscrabble economic times, that’s a weak foundation for a bold policy plan. 

That’s not the only financial problem, though. Voters have to be persuaded that the federal government can live up to its obligations to pay most of the costs of expansion, now and in the future. In the midst of sequestration, and with trillions in deficits looming for generations to come, the promise of more federal money seems to voters like a Ponzi scheme. Really? Can the government in Washington afford this? Can we trust that Congress and President Obama won’t bail out and plop the costs in the laps of state taxpayers in a year or five?

The Medicaid expansion mess is just a sub-chapter of the larger debacle that is ObamaCare. Yes, there were — and still are — problems with our healthcare delivery and financing system. I, myself, as a self-employed individual, know well the challenges of obtaining healthcare coverage, and particularly the burden of pre-existing condition exclusions in securing coverage for family members. But, as a student of public opinion, I also must acknowledge that proper reform would have been more incremental, less engineered by healthcare lobbyists and preceded by more effective cultivation of public support. Public opinion can seldom be wooed by brute force from suited politicians and lobbyists armed with little more than sketchy numbers and a promise of “free” money. Voters are smarter and more discerning than that.

Hill is a pollster who has worked for Republican candidates and causes since 1984.