Branstad has no case against expanding Medicaid (updated)

Five years ago this week, I was hospitalized with an infection that might have become life-threatening or permanently debilitating had I not had health insurance coverage, which allowed me to receive a relatively early diagnosis. Every day in this country, uninsured people hunker down, hoping their health problem will go away without an expensive doctor’s visit. That’s one of many reasons studies have shown that expanding Medicaid saves lives.

Governor Terry Branstad sounds determined not to expand Medicaid, but none of his arguments can withstand scrutiny.

UPDATE: Branstad confirmed on February 23 that he will not agree to expand Medicaid. Added details and other related news below.

Many authors have presented strong policy arguments for expanding Medicaid. If the ethical reasons to provide life-saving coverage don’t persuade you, check out some of the economic benefits. The Iowa Hospital Association explained how expanding Medicaid would improve Iowa’s business climate as well as individuals’ health and the finances of community hospitals. That association is among 48 groups, representing just about every aspect of medical care in Iowa, which called on state leaders “to expand Medicaid to Iowa residents with incomes up to 133 percent of the federal poverty level as set forth in the Affordable Care Act, in order to provide and compensate for an efficient and cost effective health care delivery system for low income Iowans who are in need of, but currently lack adequate and accessible health care coverage.” Here’s the full list of groups that signed on to the cause:


American Cancer Society Cancer Action Network

AFSCME Iowa Council 61

American Heart Association

AMOS (A Mid-Iowa Organizing Strategy)

Brain Injury Alliance of Iowa


CHAIN (Community HVI/Hepatitis Advocates of Iowa Network)

Community Health Charities Iowa

Communications Workers of America Iowa State Council

Easter Seals Iowa

Epilepsy Foundation of Iowa

Every Child Counts (Child and Family Policy Center Initiative)

HCI Care Services (formerly Hospice of Central Iowa)

Hospice & Palliative Care Association of Iowa

Iowa Alliance for Retired Americans

Iowa Alliance in Home Care

Iowa Annual Conference of the United Methodist Church

Iowa Association of Area Agencies on Aging

Iowa Care Givers Association

Iowa Catholic Conference

Iowa Citizen Action Network (ICAN)

Iowa Community Action Association

Iowa Developmental Disabilities Council

Iowa Federation of Labor, AFL-CIO

Iowa Hospital Association

Iowa Human Needs Advocates

Iowa Medical Society

Iowa Mental Health Planning Council

Iowa Nurses Association

Iowa Occupational Therapy Association

Iowa Olmstead Consumer Task Force

Iowa Public Health Association

Iowa Primary Care Association

Iowa Psychological Association

Iowa Statewide Independent Living Council

League of Women Voters of Iowa

Leukemia and Lymphoma Society, Iowa Chapter

Mercy Health Network

NAMI (National Alliance on Mental Illness)

Greater Des Moines National Association of Social Workers, Iowa Chapter

National Multiple Sclerosis Society, Upper Midwest Chapter

Polk County

Progressive Action for the Common Good

Progress Iowa

Results (The Power to End Poverty)

South Central Iowa Federation of Labor, AFL-CIO

Visiting Nurse Services of Iowa

What does Branstad think he understands that all of the leaders of all of these groups are missing? His communications director delivered this message.

Branstad has said that instead of committing to expanding the expensive joint federal and state Medicaid program, Iowans should focus on living healthier lives. He is pushing a plan to make Iowa the healthiest state in the nation, mainly by encouraging residents to exercise more and eat more healthfully.

His spokesman, Tim Albrecht, reiterated Branstad’s skepticism about the idea: “The expansion of Medicaid without any attention to outcomes fails the very people Medicaid intends to serve: vulnerable Iowans,” Albrecht wrote in an email after the press conference. “Expanding Medicaid without any attention to the funding sources, both our own and those of our federal partner fails the very people Medicaid who make the program possible: the hardworking taxpayers of Iowa.”

Albrecht said the governor’s staff is instead focusing on redesigning and extending IowaCare. That program, a current, limited offshoot of Medicaid, offers basic coverage to about 70,000 uninsured adults.

“Gov. Branstad believes we should work together to make IowaCare and Medicaid programs that focus on the quality of the outcomes for the patients they serve before we spend time discussing the expansion of programs whose only results have been high cost but low quality outcomes,” Albrecht wrote.

The IowaCare program is everything Republicans would normally rail against: a government plan that forces recipients to receive care at only two locations in the state, even if that means they have to drive hundreds of miles. IowaCare is more costly per individual covered and doesn’t allow patients to choose their own doctors. Expanding Medicaid as foreseen under the 2010 health care reform law would cover between 115,000 and 150,000 Iowans, far more than the number helped through IowaCare.

The Des Moines Register has published many editorials about Medicaid lately. Instead of responding to their substantive criticisms, Branstad authorized his re-election campaign to send out this fundraising e-mail yesterday.

“Dear Friends,” his letter says, “you probably haven’t noticed, but buried deep in The Des Moines Register, they are waging a campaign against the governor, trying to force his hand into expanding Medicaid. They do this without a care in the world as to where the extra hundreds of millions of dollars would come from, and taking no issue with the fact that this government program fails to make those it covers healthier.

“In fact, they have written 14 editorials on Medicaid expansion – just since January 22! Quite an obsession. It’s time to fight back. Will you donate $14 to battle their vicious smears? That’s just one dollar for every editorial they’ve written attacking this governor. …

“Gov. Branstad understands what the Register hides – Medicaid enrollees have grown by 65% since 2000 – while costs have increased a whopping 129%! All the while, this program fails to make Iowans healthier.

“Can’t we do better? Gov. Branstad believes we can, and has a goal of making Iowa the healthiest state in the nation, and won’t be deterred by the Register’s attempts to go backwards on this goal…”

While Branstad postures as a victim of the Des Moines Register’s obsession, let’s look at what some other Iowa newspapers have had to say on the issue.

The Ames Tribune commented in a February 2 editorial,

“This Healthiest State Initiative will assist Iowans in learning about and applying proven methods to live longer, happier, and healthier lives,” Branstad said at the time [in August 2011]. “We control more than 70 percent of the factors that influence our health. It is within our power to make a positive difference in our lives.”

That’s all well and good, and everyone knows that the choices we make in our daily lives have a huge impact on our mental and physical health. Eating well, exercising and avoiding unhealthful behaviors such as smoking all can help us maintain our well-being.

But what about that other 30 percent? The part we have no control over, such as when, despite our best efforts, we get cancer or lupus or pneumonia, or fall and suffer a head injury?

What about the indisputable fact that preventive care – the early detection of disease and regular management of chronic conditions – can not only reduce overall health care costs but also mean the difference between life and death?[…]

Branstad’s concern about the federal budget didn’t stop him from lobbying against cuts to the Iowa Air National Guard or to federal subsidies for ethanol production. Surely those expenditures also affect federal debt and deficits.

Branstad’s answer to health care access, as outlined in his Condition of the State Address in January, is to throw a few million dollars to doctors to entice them to practice in Iowa and set up obstacles to make it more difficult for malpractice lawsuits to get to court.

There really is only one word for the governor’s positions, and it is a harsh word: hypocrisy.

It is hypocritical to call on Iowa to become the healthiest state while at the same time refusing federal help to give more Iowans access to basic health care. It is hypocritical to fight for federal funding for military and ethanol interests while at the same time claiming the government can’t afford to expand Medicaid.

How about the Quad-City Times, which endorsed Branstad for governor in 2010? That newspapers’s editors argued on February 17,

Under ACA [the Affordable Care Act], Medicaid eligibility would be granted to the working poor, not just the absolutely destitute. This government coverage would allow poor Iowa families to get the check-ups and treatment they need before minor symptoms become chronic diseases. At that point, treatment gets more expensive, less effective, and everyone pays.

Expanding Medicaid puts the poorest Americans on track for better, and more cost-effective health care.

Yes, it costs billions.

But much of that cost is coming from ACA-ordered reductions in hospital and physician payments in other areas. Those savings are being invested into expanded Medicaid across the nation.

There is no good reason the poorest Iowans should be left out.

Branstad and many of his Republican colleagues are balking, claiming they don’t trust the federal government to follow through on funding promises. We find those concerns are more political than practical. The federal government has reliably funded Iowa roads, farms and schools through congressionally ordered programs. The ACA – like it or not – is a congressionally approved program. Pretending otherwise makes for petty, pandering politics – and lousy public health policy.

Instead of embracing the Medicaid expansion, Branstad wants to dump more money into IowaCares, a program that offers coverage for some poor Iowans able to seek treatment at Broadlawns Hospital in Des Moines or University Hospitals in Iowa City. That’s it. Two hospitals.

That’s a pale substitute for statewide, preventative coverage. And it will do little to make Iowa the healthiest state.

The rest of the governor’s health plan involves legislating limits on medical malpractice judgments. Medical lawsuits are declining and malpractice insurance premiums have been flat, or gone down. We’re comfortable trusting Iowa judges and juries to litigate specific facts in specific cases brought by real Iowans. The Legislature has no business blindly shielding medical providers from the consequences of malpractice.

So the governor’s only remaining healthy state initiative is Blue Zones, an innovative public/private partnership to improve wellness in a handful of targeted communities.

That effective effort will make little impact if the governor continues to block Medicaid expansion to more than 100,000 poor Iowans.

This afternoon, Branstad is scheduled to meet with U.S. Health and Human Services Secretary Kathleen Sebelius in Washington. He wants the federal government to allow Iowa to keep running IowaCare for the next two years. Iowa Senate Democrats have asked federal officials to say no. I hope Sebelius gives Branstad some pretext to back down from his stance on Medicaid, because his stubbornness threatens to hurt a lot of innocent people.

Any comments related to health care reform are welcome in this thread.

UPDATE: The Des Moines Register’s February 20 editorial underscored more problems with Iowa Care.

“We find that nearly all our IowaCare patients must be taken to the U of I,” the director of a city ambulance service in northwest Iowa said in an email to us. “It’s a round trip of more than 450 miles, costing more than $600 in fuel and personnel, plus the cost of any equipment or supplies. The bill would be about $3,500, but IowaCare does not cover the cost of any transportation for patients.

“Obviously if a patient is enrolled in this program, they more than likely do not have an extra $3,500 to pay, and these charges are typically written off,” the director said.

The “true tragedy,” he points out, is patients could receive great and less expensive treatment closer to home, including at a top-notch cardiac facility near him. Those patients could do that if the Legislature and Gov. Terry Branstad agree to expand Medicaid.

SECOND UPDATE: I’ve never found much to admire about Ohio Governor John Kasich, but here’s what he said about Medicaid during his State of the State address this week.

Kasich methodically ticked through segments on job creation, past legislative successes and his proposed budget as it relates to taxes, the Ohio Turnpike, school funding and higher education.

But he reached back for something extra on Medicaid, perhaps, in part, because many of the 59 Republicans in the Ohio House and the 23 in the Senate are queasy about the idea.

The expansion – an option under President Barack Obama’s Affordable Care Act – would provide health care for hundreds of thousands of poor Ohioans and be funded fully for three years by the federal government. Kasich defends it because of the $13 billion he says it will return to Ohio over seven years and because of the funding it would free up to treat the mentally ill.

“I can’t look at the disabled, I can’t look at the poor, I can’t look at the mentally ill, I can’t look at the addicted and think we ought to ignore them,” Kasich said. “For those who live in the shadows of life, for those who are the least among us, I will not accept the fact that the most vulnerable in our state should be ignored. We can help them.”

Earlier yesterday, the Ohio Liberty Coalition, a network of tea party groups, threatened a primary challenge for any Republican lawmaker who votes in favor of the expansion.

“I know it’s controversial,” Kasich said, before he called out a Republican representative by name. “We’re not ignoring the weak. Jim Buchy (of Greenville), the Lord doesn’t want us to ignore them.”

Meanwhile, Iowa’s governor is trying to spin his stubbornness on Medicaid into campaign contributions.

SATURDAY UPDATE: Speaking to the Associated Press in Washington, Branstad said he told Health and Human Services Secretary Sebelius that he won’t expand Medicaid in Iowa.

Branstad said he pressed Sebelius for a federal waiver to continue IowaCare, a health care program that provides limited benefits to 70,000 low income adults in the state. That program is set to expire later this year.

“I am very comfortable that we have made the right decision and we are going to continue to pursue this waiver and we’re working with them on a partnership exchange and that’s what I told Secretary Sebelius,” Branstad said between meetings as part of the National Governors Association meeting in Washington. “We are interested in making Iowa the healthiest state. We have kind of set our direction.” […]

“Every governor has got to look at their own situation,” Branstad said. “We’re fortunate in that we don’t have as many uninsured that a lot of other states do.” […]

“We want to cooperate with them as much as we can but we’re not going to buy into a ’60s federal program that’s unaffordable and unsustainable,” Branstad said. “Because we think the whole thing in the end will either collapse or the burden will be pushed onto the states in a very significant way.”

He could have done what Governor Rick Scott is doing in Florida: agree to a three-year Medicaid expansion, with plans to re-evaluate later, depending on federal funding levels.

The bottom line is that Branstad would rather spend more to provide fewer Iowans with inferior coverage through IowaCare.  

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  • It's not about the money

    Branstad’s office argues that 10% of the expanded Medicaid costs (after the first three years of no cost) will just be too much for Iowa taxpayers to bear.  Above all else the state budget must be protected. There are two inevitable conclusions to draw from Branstad’s financial opposition to Medicaid expansion.  One is that Branstad has absolutely no faith in his own administration’s ability to improve the Iowa economy by the time the Iowa 10% kicks in even though he constantly touts his ability to create jobs and a favorable business climate.  The second conclusion is Branstad is so beholden to the right wing of the Republican party that he is blind to the overwhelming majority of the leaders and professionals in the health field supporting the expansion.  It’s a tough question for the governor of Iowa to either do the right thing or follow the right wing.

  • As you may surmise already....

    I have no problem putting brakes on a program that has no history of any control of costs and at the same time is clearly expanding rapidly in a seemingly out of control fashion.

    Branstad is doing exactly the right thing.  Until the federal government can get a handle on even one program, there is no business that Iowa has writing a blank check to the future at the expense of its taxpaying residents.

    • even Rick Scott

      not the sharpest knife in the drawer, figured out that no one benefits from denying care to people who would be eligible for Medicaid. He said Florida will re-evaluate its position in three years, depending on whether the federal government keeps up its obligations.

      Branstad is throwing in his lot with Bobby Jindal and Rick Perry. Rick Snyder and John Kasich are a heck of a lot smarter.