COMMENTARY: Medicaid Expansion: Principle, People and Peril

OKLAHOMA CITY – “Liberalism, of course, professes to speak for ‘the poor,’ even though, given a choice between the poor themselves and a program whose real effect is to hurt the poor, it will choose the program,” wrote the late iconoclastic conservative writer Joseph Sobran.

Sobran loved people in the flesh, rather than as symbols. He was often misunderstood. I usually but not always agreed with Joe. I honor his memory, and the rigor with which he looked at policy in late Twentieth Century America.

For decades, I learned a lot from watching Sobran, including the perils of making a point powerfully but without nuance. Still, I loved and respected the man. He became a pal on my first-ever visit to New York City and the offices of National Review magazine, back in the day. 

We see the truth in Joe’s blunt assessment in today’s debate over Medicaid, where arguments for the expansion of coverage envisioned in the Affordable Care Act are usually made in moral terms — especially since Florida Gov. Rick Scott’s flip-flop. 

But: Is it more immoral to destroy a system that works, however imperfectly, for most Americans, and replace it with a system that will collapse, one in which the poor and everyone else will witness unprecedented stress and strain?

“Putting millions of additional people into a program that has been struggling with access to care for the past forty-five years is likely to result in worsening access for those who are currently enrolled,” according to Joseph Antos of the American Enterprise Institute, writing for the Journal of Health Politics, Policy and Law.
Michael F. Cannon of the Cato Institute notes that expansion makes these new Medicaid patients (some of whom already had private health insurance, by the way) “dependent on government for their health care, and thus would expand the constituency for more government spending and higher taxes” — all while providing them inferior access to care.

Back here in the promised land, the Oklahoma State Medical Association (OSMA) worries that the addition of 200,000 people to Medicaid in 2014, which could still happen if Gov. Fallin does not resist expansion, would crater any ability to care for patients, poor or otherwise, in a sustainable way.
Oklahoma already ranks near last in physician-to-patient ratios. “It’s pretty cynical to say, ‘Yes, you’ve got coverage, but you can’t see a doctor for two years.’ So we’re worried about the workforce issue,” OSMA’s Kenneth King told Jennifer Lubell of 

Health-care researchers Avik Roy and Grace-Marie Turner put it this way: “The Medicaid program is so badly broken that it actually harms the people it is intended to serve. Mountains of clinical literature show that, on average, patients on Medicaid have poorer health outcomes than those with no insurance at all. The largest such study by far, conducted by surgeons at the University of Virginia, examined outcomes for 893,658 individuals undergoing major surgical operations from 2003 to 2007.

 It found that patients on Medicaid were 13 percent more likely to die in the hospital after surgery than those with no insurance, even when adjusting for age, gender, income, region, and health status. Medicaid patients were 97 percent more likely to die than those with private insurance.

 “This is because the Medicaid program pays doctors and hospitals far less than private insurers do. … As a result, many doctors refuse to take Medicaid, and when Medicaid patients can’t get predictable access to care, their cancers go undiagnosed and their heart conditions go unmanaged.” 

In February, Oklahoma Gov. Mary Fallin explained her decision to keep Medicaid management here at home: “Choosing not to expand Medicaid as proposed in [the Affordable Care Act] was the right decision for Oklahoma. The president’s expansion is unworkable and unaffordable for our state. Some estimates show expanding Medicaid would cost Oklahoma an additional $689 million.
“Instead, we are focusing on an Oklahoma plan to improve the health of our citizens, lower the frequency of preventable illnesses like diabetes and heart disease, and improve access to quality and affordable health care.” 

If Fallin sticks to her guns, there might still be a state, and an economy, where people, including the poor, can fashion better lives for themselves as they deem best, in keeping with American traditions of personal liberty.

For months, in long, heartfelt and sincere political and policy discussions with friends on the Left – people I love and respect – the issues of “ObamaCare” and Medicaid expansion have been the main subject matter. 

I do not want to believe that Sobran’s maxim is true of my liberal friends, but I feel it is true of the broader statist impulse that advances every year, every month, every week, and every day in my beloved country.

In the present zeitgeist, given a choice between “the poor” — as individuals with hearts, minds, souls, and possibilities — and a public policy that puts programs in charge of people, the program will win.
This expansion of government is without precedent. Even if the Supreme Court says that taking control of the health industry is permitted, even if the Court calls the individual mandate a tax rather than a penalty, even if it is asserted that a federal statute enacted dubiously trumps more than two centuries of constitutional limits on federal government power — this expansion of compulsion is unmatched in our federalist history.

Government is limited because human beings are flawed creatures.

There is no committee that can rationally decide in advance what is best for any one of us, no panel of experts that can dictate to families how the final days or weeks of their loved ones should be spent, no possibility that centralized treatment of diverse human belief systems can be truly just.

Our government is assuming powers that belong with individuals, communities, and “mediating institutions” such as churches and other support networks. On that path lies cultural disintegration.

 In the end, the entire structure of ACA violates the spirit of the Constitution, American traditions, and the accumulated wisdom of past generations. They understood: Excessive power corrupts.

NOTE: This is adapted from McGuigan’s essay in the March 2013 edition of Perspective Magazine, monthly publication of the Oklahoma Council of Public Affairs. 

You may contact Patrick B. McGuigan at and follow us on Twitter: @capitolbeatok.