Can Republicans regain their sanity on health care?

In the recent history of domestic governmental cruelty, few things can equal the decision by Republican-run states to refuse the expansion of Medicaid contained within the Affordable Care Act.

As a result of former President Obama's signature legislative achievement, the federal government came to states and said, "Here's a bunch of money to provide health coverage to tens or even hundreds of thousands of your poor citizens who don't have it. You'll only have to contribute a tiny bit, and it'll make your state healthier, wealthier, and happier. What do you say?" Nineteen states responded, "To hell with that."

But now things have changed. The effort by the Trump administration and the Republican Congress to repeal the ACA has failed. Perhaps more importantly, Barack Obama is no longer in office — and it was Republicans' venomous hatred of the former president and any law that had his name on it that made signing on to the Medicaid expansion so unacceptable. With Obama out of the picture, they should be able to make a rational assessment of the benefits and costs of the Medicaid expansion for their states. But will they?

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We saw one glimmer of hope this week, as the Republican-controlled state Senate in deep-red Kansas passed a bill accepting the expansion; it passed the state House, also Republican-controlled, last month. If it were signed by Repubilcan Gov. Sam Brownback, 150,000 Kansans would gain coverage.

Alas, there's the problem: Brownback, who has all but run the state into the ground with a wave of tax-cutting that hobbled the state budget and led to brutal cuts in services, has pledged to veto the bill.

Who knows, maybe he'll change his mind, or maybe the legislature will muster the supermajorities necessary to override his veto (as of now they're just a few votes shy in each house). But the fact that this bill passed at all shows that something is changing, and previously resistant Republican lawmakers are beginning to wake up to what a great deal Medicaid expansion was all along.

The most common argument state Republicans have made against accepting the expansion — "We can't afford it!" — was always bogus. First, the federal government picks up 90 percent of the tab, for a program whose cost had traditionally been shared equally between Washington and each state. Second, study after study has shown that the Medicaid expansion actually saves states money. As a literature review conducted by the Kaiser Family Foundation recently concluded, "National, multi-state, and single-state studies show that states expanding Medicaid under the ACA have realized budget savings, revenue gains, and overall economic growth."

This was exactly what advocates of the ACA predicted: Once you insure a bunch of low-income people, hospitals no longer come to the state looking to be reimbursed for uncompensated care (people showing up in the emergency room who end up unable to pay because they don't have insurance), tax revenues from medical industries go up, and a workforce with more health security ends up being more productive.

So states that refused the expansion weren't just screwing over their own citizens, they were hurting their state budgets and overall economy as well.

Conservatives will no doubt object that what I call heartlessness is actually a philosophical objection on their part. Medicaid is, after all, a Big Government program, and therefore they consider it inherently pernicious. Any effort to expand it should be resisted, so that liberty may prevail.

That's certainly how they feel, but that position has a direct price in human suffering. The people we're talking about have no other option for health coverage. To return to Kansas, under their current rules, if you earn more than 33 percent of the poverty level — which would be a princely $8,200 yearly income for a family of four — the state considers you too wealthy to be eligible for Medicaid.

Under the old rules — still the rules for states that refused the expansion — each state sets its own eligibility levels. Not surprisingly, Republican states are much more stingy. In Texas, for instance, the cutoff for eligibility is an incredible 15 percent of the poverty level. A family of four earning $3,700 makes too much to get Medicaid. That's why there are over a million uninsured Texans who would get coverage if the state would accept the Medicaid expansion. But the legislature and Gov. Greg Abbott — who makes his predecessor Rick Perry look like a bleeding-heart hippie — are adamantly against it.

There's another argument opponents of the expansion sometimes make that's worth addressing. "To expand ObamaCare when the program is in a death spiral is not responsible policy," says Brownback's spokesperson, and this is a justification many other Republican states offer for their refusal to accept the expansion. It happens to be false — the ACA has issues, but is hardly in a death spiral. More importantly, the problems that the ACA has experienced have been centered on the individual market and the exchanges, which are entirely separate from Medicaid. The Medicaid expansion is doing exactly what it was intended to do: Give health coverage to people who couldn't afford it otherwise.

There are some states still considering the expansion; a measure to accept it will be on the ballot in Maine this year, Democratic Gov. Terry McAuliffe of Virginia is still trying to convince his GOP-controlled legislature to accept it, and the Republican governor of Georgia has hinted that he might be open to expansion in some form. So perhaps, as the days go on and the urgency of shaking their fists at Obama fades, some of these states might consider doing right by their own citizens. It might only take a couple of them to make it feel like it's something Republicans are allowed to do. That won't make up for how cruel it was to deny coverage to their citizens for so long, but better late than never.