Considering Medicaid Expansion – Mental Health Services

The Kansas City Star's November 17, 2012 editorial on the need for honest analysis before decision-making on Medicaid expansion was unusual. I was particularly struck by the illustration of potential Medicaid expansion savings by shifting much of the cost of recipients of state mental health services from the states to the federal government.

Rather than parse the entire editorial for factual accuracy, I would rather comment on its general tone.  The KC Star cannot make the case for even considering the Medicaid opt-in as a balance sheet matter without first explaining to its reading public the tremendous roll government (both federal, state, and county) already plays in funding health insurance in the United States.

Suzanne Mettler's The Submerged State is a book about the costs to democracy when the government's subsidizing hand is hidden. You can read a bit about it here: http://www.press.uchicago.edu/ucp/books/book/chicago/S/bo12244559.html  Her point is that we hide much government subsidization behind tax policy (think the mortgage interest deduction) as a way of hiding the very nature of direct subsidization and cross-subsidization itself, thereby robbing our citizenry of the vocabulary necessary to have an informed debate on much of this subsidization.

How does this apply here?  I am guessing the KC Star editorial board imagines a significant percentage of its readership would be astonished to learn that the government — both state and federal — already subsidizes some mental health care to low income and indigent individuals. They might also be surprised to learn something the Star did not point out — that a number of states have spent much effort, since 1983, perfecting cost shifting maneuvers designed to game their way out of the state share of some of these agreements. Sounds like the Star is urging Kansas and Missouri to join the crowd.

Part of the ACA's simplification of Medicaid funding to the states for those newly eligible under Medicaid expansion was to simplify the system for beneficiaries but also to simplify the system as a matter of policy — rendering it both more transparent and more debatable in the public arena.