After my most recent post regarding Medicaid,  health insurance exchanges, Alabama and the Affordable Care Act, I was asked to put together some thoughts for publication in a local paper, which can be found here.  The paper (on Sunday there is a print version to go with the web presence) published my personal e-mail along with my name at the beginning of the article so I have spent part of the day fielding reactions from folks who feel compelled to let me know how they feel about “ObamaCare,” Medicaid, or me personally.

My favorite comment was also (go figure) the most positive. He started out by pointing out that “Our State is not ‘poor’; it just refuses to prioritize healthcare.” He goes on to say

Our current President stated early-on that he would rather be a one-time office-holder than fail to stand for and do “the right thing.” Politics has been defined as “the art of the possible.”  I know a young man who would be considered as one of the “working poor” who cannot afford to purchase health insurance but who is an industrious, hard-working adult focused on his job and the welfare of his daughter.  Fortunately, because he lives outside of Alabama, if he has been unable to increase his income to more than 133% of the poverty level by 2014, he can access Medicaid until his personal economics improve.  Our fellow citizens similarly-situated deserve the same opportunity.

I like this man.

On the other hand, I also heard from a gentleman who feels quite differently and made it clear that he held me personally accountable should Alabama opt for the Medicaid expansion:

Normally, after reading such an article, I have grown to either groan, or fervently wish for the days of reconstruction to return to the South, when ignorant southern males were either horsewhipped or simply tarred and feathered for their stupidity and deception. … Shame on you for writing such a piece of trash.

He then expresses 4 concrete concerns which I will try to answer:

1) You mention that approximately 350,000 people could be added to the Medicaid expansion. But, how do you pay for them? There are no free lunches in covering Medicaid enrollees.

Most of the cost will be carried by the federal government for the first 6 years. My read of the the last election was that most Americans see the need to pay for services that are necessary. Most of us agree that everyone is entitled to some form of healthcare and the ACA is a way to better organize and pay for it (from an idea put forth by the Heritage Foundation). As to why some states are yelling more loudly than others, Kaiser Family Foundation points out that there are lies, damn lies, and accounting tricks at the state level. As I said in the article, it isn’t like they weren’t getting sick before the ACA was passed.

2) You cite that for every $1 of Medicaid spending, Alabama realizes $8 in return. Where did you get those numbers?

Mostly from here although I have had access to private information that confirms this for Alabama.

3) You cite that this will cost us $100 million in matching money, although this will increase slightly in 2020. States live with balanced budgets, and many would have trouble paying for even a minimal expansion. And, once added, the costs will continue to rise per enrollee. There will be significant costs prior to 2020.

We could increase our tobacco tax by $1 a pack and still be below that of Mississippi, Tennessee, and Georgia. This would cover the cost.

4) Rural hospitals and doctors ought to be picking up more and more of the costs. You guys wanted the Affordable Health Care Act, so now pay for it. I see no where in your article where you have volunteered to pay an additional income tax out of your overpriced salary for such an expansion. How about if we reduce your salary 75% to help pay for the expansion?

I hope the governor elects to find a more equitable way to pay for covering Alabamians. I have pointed out before how tenuous the state of rural health is in Alabama. As to reducing my salary…

Not being content with this, he also closed with a special invitation for me as well:
Given the fact that you were too lazy, or deliberately deceptive about knowing the truth before you wrote this piece of trash, let me make this very personal to you. I think that you are a deceptive liar, an ignorant southern male, who is either too lazy or stupid to write the truth, and one who has no sense of shame. I think you deliberately mislead [sic] the public with this article. I think that you are simply a lazy southern jackass baying in the wind pining for a program that cannot be paid for and an expansion that could end Medicaid in this state. In the end, someone ought to brand the word stupid on your forehead and send you packing out of this state. We have far too many lazy, ignorant southern males living here. Do us all a favor and leave Alabama.
Or, maybe I’ll stay just to be a thorn in your side, Reverend.