October 16, 2013
As originally published in the New Hampshire Union Leader
The Medicaid commission that ended this week was a well meaning distraction that won’t produce a compromise but may lead to some constructive conversations. Policymakers, notably the governor and the senate president, can use the commission as an example in both good ways and bad. In that respect, perhaps the commission was a useful first step toward a productive discussion.
In the budget process in June, a divided state government could not agree on any one approach to the federal enticement toward a large scale expansion of the state Medicaid program. The governor and the House insisted expansion be part of the budget, the Senate took it out. As a compromise, the budget created a commission to study Medicaid expansion with the majority of members appointed by those supportive of the expansion envisioned by the president and the governor.
I had the mixed blessing of being appointed to that commission which ended its existence on October 15th. Ultimately, some of the work of the commission will be used by lawmakers trying to negotiate some sort of compromise between those who want additional coverage and those worried about the financial risks and unintended consequences inherent in expanding Medicaid caseloads by about 50%.
For those policymakers seeking some common ground, the commission is an example of exactly what not to do but also an example of a path out of a messy mix of mistrust and politics.
The commission ended up beset by predictable pitfalls. From the beginning there was tremendous mistrust between minority and majority factions – more from outside the commission itself than within. It’s natural that a majority, convinced of the wisdom of their cause, might regard skeptics as politically motivated and more as saboteurs than conscientious objectors.
Unfortunately, that led to an overly scripted and less-then-open initial commission. Questioning was attacked, technically anonymously but only technically, as “building the case for an ideological crusade.” Data requests, apparently, are quite dangerous.
The tension led to frustration and a willingness to dismiss the commission as a meaningless sham. One observer noted “show trials are usually better choreographed” (that may have been me). Gradually, politicians who would ultimately be involved in any decision regarded the commission as something of a meaningless sideshow.
The mistrust, the willingness to assume sinister motives, and the eagerness to at least try to choreograph behind the scenes is an example to be avoided by politicians.
On the other, after three months of neutering itself, the commission created examples of what might work for people ultimately involved in the real decision. Meaninglessness created opportunity. When the outcome became very low stakes indeed, people were able to be more open.
The final three weeks of the commission became a model of discussion, dialogue, and exchange. Much of the responsibility for that change falls to Rep. Tom Sherman of Rye. Dr. Sherman is likely as liberal as I am conservative but inaugurated a discussion phase by putting a tentative plan together and being willing and eager to engage in wide ranging discussion with anyone regardless of whether or not they were likely to agree with the final product.
The only real downside to those few weeks is that time constraints pressured us and limited some discussion areas. Had those three weeks of open conversation began the discussion rather than ended it the commission might have been a very different animal.
Going forward, any negotiation has to be a real negotiation not an attempt to get one side or the other to lose and harm their electoral chances next year. A year ago, people might have argued that the federal government is asking us a yes or no question – either we expand in precisely the way they suggest or we don’t. That thought needs to be abandoned.
The populations the state might expand to are not one bloc. Almost half of them currently have health insurance, the other half do not. A fraction of those who don’t currently have insurance have access to subsidized insurance through the exchange. None of those groups should be treated precisely the same.
Too much time is spent wondering if the federal government will permit something instead of wondering if it’s a good idea. “I don’t think they’ll let us do that” is not an acceptable argument. Any compromise that is acceptable will necessarily involve things that are not off the federal shelf. And playing “mother may I?” with the federal government is never a recipe for making good decisions.