Harold Pollack has a nice piece on the choice facing Red States regarding the ability to opt out of the Medicaid expansion in the ACA. He includes a map of Congressional districts that were considered “whip districts” for Democratic Representatives for the March 2010 vote on the ACA in the last Congress (in N.C. you can see that Mcintyre, Kissell and Shuler all voted no).
The point of the map is that most of the Dems who voted against the ACA represented districts with relatively high rates of uninsurance, so their no vote could be understood as being against the self interest of the people they represented. Of course, these Representatives voted no because the ACA was unpopular in their district, and they were mostly within states with strong Republican rule (in N.C. this was just before Republicans took control of the state House and Senate in Nov. 2010, at least partly due to anger about the ACA).
The ruling by the Supreme Court that states can now opt out of the Medicaid expansion in the ACA with no financial penalty to the state’s existing Medicaid program sets up a very important, and clarifying choice for North Carolina and other states. I think that is good, because we need to move beyond the general political equilibrium of the past 50 years or so in which much of the political establishment in the South railed against the evils of the federal government, while the net flow of federal money is roughly from the Blue states to the Red ones (with Texas being an exception (link for map below; interesting N.C. only analysis showing that 30 years ago N.C. was a net donor state).
States shaded as white above pay more in federal taxes than they receive in federal dollars, so are “net donor” states. Darker states are “net recipients.” North Carolina received $1.08 in federal expenditures for every $1.00 in federal taxes paid in 2005 (latest year I could find this analysis).
There will never be an easier way for states to greatly expand health insurance coverage to low income residents than via the implementation of the ACA (between 560,000-700,000 North Carolinians could be covered via the Medicaid expansion, with the federal govt paying 100% of the cost for the first 3 years, and 90% for the next 7). I realize that many have deeply held philosophical objections to federal programs and there are long term funding uncertainties, so I am open to hearing suggestions from my fellow North Carolinians about a better way to expand health insurance coverage in our state.
I suspect that deciding whether North Carolina will take the Medicaid expansion or not will become a key issue in all General Assembly races as well as a central one for the Gubernatorial one in November, as it should be. I am not sure what we will decide, but it strikes me as good and correct that if we as a state decide we are opposed to a federal program to address a public policy problem, that our opposition in this case will not only be rhetorical and noisy, but consequential and real. My guess is we will have more such real choices in the future.
This is an important decision for our state.
update: revised slightly.