In the current fight over expanding health-care coverage to low-income people, Republican state leaders often deploy some version of this argument: States shouldn’t accept billions in federal money to expand their Medicaid programs because the debt-burdened federal government won’t keep its financial commitments. Responsible leaders shouldn’t structure their budgets on the fiction that the federal government will maintain the same level of support in the future, lest states be left with the expansion bill years down the road.
But in policy areas outside the Affordable Care Act’s Medicaid expansion, GOP state leaders don’t demonstrate the same amount of concern that a tottering federal Treasury is likely to renege on its obligations to the states. In fact, Republican state budgets suggest the opposite view.
According to a new analysis from the Pew Charitable Trusts (h/t Niraj Chokshi), Medicaid-refusal states are already heavily dependent on federal money to support various programs. All states are: In aggregate, states got 30 percent of their revenue from the federal government in 2013. A large chunk of that federal assistance funded the states’ pre-expansion Medicaid programs, but federal cash also flowed into infrastructure, education and other reasonable priorities, according to the Census Bureau. The state least dependent on federal money is oil-rich North Dakota — yet it still got 19 percent of its revenue from the Treasury.
Here’s the kicker: The states that are the most dependent on the federal trough are GOP anti-Medicaid expansion holdouts. Of the 11 states that got the highest proportion of their revenue from federal grants in 2013, 10 of them have refused to expand their Medicaid programs — even though the Affordable Care Act committed the federal Treasury to covering nearly all of the expansion costs, which means that ACA Medicaid expansion comes on better terms for the states than many other federal grant programs.
“There is a very real possibility the federal government, which has saddled itself with outrageous debt, will not even have the money to pay for some of the promises it has made,” Mississippi Gov. Phil Bryant (R) wrote in a 2013 anti-expansion commentary. Yet federal money accounts for a larger portion of state revenue in Mississippi — 43 percent — than in any other state.
Louisiana comes in second on the list. Gov. Bobby Jindal (R) wrote this against Medicaid expansion in 2013: “All federal government programs end up being more expensive than originally planned, and the federal government is already mortgaged to the hilt.” Louisiana gets 42 percent of its revenue from the feds.
Tennessee lawmakers just rejected a Medicaid expansion proposal. Here’s Tennessee state Rep. Jeremy Durham in 2013, according to the Heartland Institute, a conservative think tank: “The federal government has gotten itself into a very precarious financial situation and is in no condition to offer such a ‘bargain’ to states.” Forty percent of Tennessee’s revenue comes from Washington, putting it third on Pew’s list.
If GOP leaders believe that a “precarious,” “mortgaged” federal Treasury is so burdened by “outrageous debt” that it won’t be able to keep its end of the Medicaid expansion bargain, they should apply the same concerns to all sorts of other commitments they have accepted from the federal government. But it’s a lot more likely that Republican state leaders are willing to rest their budgets on the cornerstone of state-federal cooperation — except when that cooperation comes under the label of Obamacare.