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Medicaid Extortion


Stanley Feld M.D.,FACP,MACE

This topic is obscure. It is important because it is a defense of states rights opposed to federal control. The Obama administration wants to control states decisions through the use of subsidies 

I will try to make the issue as clear as possible.

The Obama administration has threatened to decrease funding of Medicaid in states (Florida, Texas and other states) that have declined to expand their Medicaid program.

The reason these states have declined to expand Medicaid is because at the end of two years these states would be stuck with increased costs they cannot afford to pay.

The Obama administration volunteered to pay all expenses for the first two years. When states that have expanded Medicaid under Obamacare are forced to raise taxes and increase their budget deficit, the people in those states will scream. The state will be hurt economically.

Obamacare and the state health insurance exchanges were designed to shift the financial responsibility for Medicaid from the federal government to the states. This action will drive the state budget deficits higher while slightly decreasing the federal deficit.

The federal government can print money. State governments cannot. State governments are required to have a balanced budget or an excess. A budget excess would result in lower state income taxes.

In June of 2012 the Supreme Court upheld the constitutionality of the Affordable Care Act by changing the “individual mandate” penalty for non-compliance to an individual tax.

I thought the court decision was wrong.

Americans must abide by the Supreme Court’s decision. This part of the decision captured the most media attention.

At the same time the Supreme Court struck down the Obamacare provision that let the federal government withhold Medicaid funding from any state that did not expand its Medicaid program or form a state insurance exchange as prescribed in the law.

 “This coercion of state governments—a “gun to the head,” as Chief Justice John Roberts put it—was a blatant violation of the constitutional principle of federalism.”

 The traditional mainstream media did not advertise this ruling widely. Many do not fully appreciate the significance of the ruling.

It is a decision in favor of states rights.

The traditional media has criticized the governors of Texas, Florida an eight other state governors that did not set up state health insurance exchanges. The criticism was that those states were wasting billions in federal funding.

In reality the ruling was a major blow to Obamacare. These governors know that Medicaid is a failed entitlement. All Obamacare did was expand Medicaid coverage to cover everyone earning less than 138% of the federal poverty level.

They knew they will be stuck with the cost overruns from a failed entitlement that did not fix the healthcare system. The ultimate result would raise taxes. These state were looking for a healthcare coverage program that would work and be budget neutral. Medicaid has not been budget neutral.

Everyone above 138% of the federal poverty level income threshold would get a subsidy to buy private coverage through the state health insurance exchanges.

The Supreme Court’s ruling has not bothered President Obama. He has a plan to get around that ruling. He has threatened to withhold more than $1 billion in Medicaid funds due the state of Florida under a waiver program first approved in 2005.

President Obama is threatening to cancel a five-year $29 billion dollar Medicaid waiver approved in 2011 for Texas.

Florida’s governor Rick Scott is suing the federal government for threatening to withhold that $1 billion. Greg Abbott Texas’ present governor will probably sue the federal government next. It will once more go to the Supreme Court.

The Obama administration is trying to get around the Supreme Court’s ruling .The scheme is called “cooperative federalism”.  Congress taxes a particular state’s residents. Congress then offers to give some of the revenue back to the state in exchange for that state adopting federal policies that the state had heretofore declined to adopt on its own.

President Obama is going to have a few problems. He needs a Democratic controlled Congress to pass the law to tax some states.

Medicaid payments are complex and vary from state to state. In Florida and Texas, Medicaid waivers allow these states to experiment with new forms of Medicaid coverage.

It is a smart move because Medicaid is a failed entitlement that needs a paradigm shift or a new system. States are supposed to be able to experiment with new ideas using these waivers..

 “States must get federal approval for their waivers, and although technically most are limited to five years, in practice they can be renewed or extended indefinitely. Some state waivers are decades old.”

Florida and Texas have waivers and get federal funding to pay for uncompensated care payment to hospitals treating Medicaid patients and the uninsured. 

The Obama administration informed Florida and Texas that expansion of Medicaid “would reduce the need for uncompensated care in the state and therefore he would link the waiver to expansion of Medicaid. If a state did not accept Medicaid expansion it might endanger the renewal of its waiver.

This sounds like extortion to me. I think Governors Scott and Abbott believe it sounds like too.

Chief Justice Roberts noted in the court’s ruling that Medicaid expansion under Obamacare “accomplishes a shift in kind, not merely degree.

“ Medicaid “is no longer a program to care for the neediest among us, but rather an element of a comprehensive national plan to provide universal health insurance coverage run by the federal government. ”

The Supreme Court found the conditions on federal funding of Medicaid to be coercive . 

When federal funds with conditions attached comprise such a large portion of a state’s budget, states do not really have any choice but to comply to the federal government’s wishes.

 States will find themselves unprotected from coercion by the federal government once they enter into the cooperative federalism scheme that President Obama and his administration concocted to bypass the Supreme Court’s ruling.

This example represents another trick play by President Obama and his administration in order to control and limit states’ rights.

I believe Chief Justice John Roberts understands this and the court will rule against the Obama administration.

However, the Obama administration’s threat will result in a huge waste of taxpayers’ dollars at both the state and federal level.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone

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