• Practical and moral
    April 12,2014

    An astonishing figure surfaced in a recent column by Paul Krugman in The New York Times. He said that 7,000 to 17,000 people are likely to die each year as a result of the decision by about half the states not to join in the expansion of Medicaid authorized by the Affordable Care Act.

    He was citing one study; critics of Obamacare may be quick to dismiss the claim as alarmist. But for the sake of argument, it’s worth considering the implications of the claim and what it says about the way health care works, or doesn’t work, in the United States.

    Medicaid is the program that serves low-income people who lack other health care coverage. One way that Obamacare devised to extend coverage to low-income people without health insurance was to broaden the reach of Medicaid so additional millions of Americans could enroll.

    The U.S. Supreme Court undermined the effort to expand Medicaid in the decision by Chief Justice John Roberts that upheld the Affordable Care Act. Roberts also ruled that the federal government did not have the power to compel the states to expand Medicaid. Thus, about half the states, governed by Republicans, decided to reject the billions of dollars that would have been provided by the federal government to pay for health care. They justified the decision by saying that they didn’t want to be caught in future years having to pay for an enlarged Medicaid program when the federal government reduced its contribution. A more cynical reading of their decision was that they didn’t want to lend support to an effort to provide health care coverage for the poor.

    Consider a worst case scenario — such as an obese, unemployed alcoholic with multiple health problems, perhaps including liver disease and diabetes. Call him Joe. The average taxpayer might be inclined to the belief that taxpayer money should not go to the care of someone who had ruined his health by his own bad choices. Resentment of that sort is an understandable response. But there are three reasons to look beyond that natural form of resentment.

    One is practical. Hard cases like Joe’s suck up a huge proportion of the health care budget. Joe eventually ends up in the emergency room of his local hospital, probably multiple times, costing the system billions of dollars. A program in Camden, N.J., found that by targeting a small number of people like Joe for focused, consistent care, major savings were achieved for taxpayers and the health care system.

    The second reason is also practical. Most of the people who would be covered by expanded Medicaid are not like Joe. They are healthy working-class people with many obstacles on their path toward a stable, productive life. Helping them get reliable health care improves the stability of families and economic productivity.

    The third reason is moral. Our society has decided we will not turn our back on Joe. That’s why we treat him when he turns up at the emergency room. But there are more efficient, cost-effective ways to treat him.

    The numbers cited by Krugman suggest that thousands of people like Joe will die needlessly in those states that have spurned Medicaid expansion. Vermont is not one of them. In fact, even before the Affordable Care Act, Vermont had expanded Medicaid through several programs for low-income people. Those problems have now been folded into Vermont Health Connect.

    These are practical and moral choices. We know that the people who have benefited from Obamacare, including the expansion of Medicaid, include millions of children and working families who have no other avenue toward health care. There is nothing undeserving about them. Lifting them up lifts up the nation. But even if we are inclined to believe that there are people who fall into the category of the undeserving, it serves the nation to provide care for them anyway. How are we to decide who is and isn’t deserving of the Good Samaritan’s help? Ultimately, the effort to expand health care in America is a moral plus.

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