Conservatives believe that the health care futures of those living on the margin with chronic diseases need to be secured. 

Medicaid expansion utilizing 60,000 young healthy adults in an integrated risk pool jeopardizes the futures of the most vulnerable of our citizens.  The 20,000 people in the gap with chronic conditions that preclude their being employed and being able to take care of themselves could obtain better coverage through a self-insurance program from the Department of Health and Welfare that could purchase $10,000 policies for each of them at a cost to state and federal governments, or $200 million.  Buying all 80,000 people a $5,000 policy would cost $400 million.

The uninsured numbers have gone down significantly over the past eight years, not because of Medicaid expansion or the health insurance exchanges but because the unemployment rate has gone from 9.5 percent to 4 percent.  People who have jobs have health care insurance either purchased by their employers or through the individual market.In states that expanded Medicaid the uninsured rate has gone down by just over 50 percent, but in states like Idaho, the national rate has gone down almost 30 percent.  In every state that has expanded Medicaid, the per capita costs and the enrollment numbers have gone up on average by 108 percent.  We already have expanded Medicaid in Idaho, increasing both numbers enrolled by 24 percent and by spending from the general fund from $350 million to $550 million.  Any claims of increased access to care and a lower ER admission rate have proven to be false.  In Idaho, Medicaid patients utilize the ER at a higher rate than those with commercial coverage and their waiting times for routine and subacute appointments is almost double what the average person experiences.

Our next-door neighbor, Oregon, has experienced a $1.4 billion deficit in its Medicaid program since expansion, with $165 million due to ineligible enrollees.  Now, the Oregon legislature is trying to pass a $600 million tax increase just to maintain the program.  The story is even worse in Ohio, where cuts to education, transportation, and infrastructure are contemplated in addition to tax increases.

When these programs implode as they did in Idaho in 2011, the patients on the margin who were the ones that the programs were originally intended for will be the ones that will suffer.  Not the young and healthy.The subsidies to providers, tax credits to customers, and risk corridors to insurers all act to increase the cost of care.  Until we address the cost side of the health care equation, as only unfettered markets can do, the rise of the private insurance marketplace in single-payer countries like Canada and Great Briton only points out that top-down government solutions only make matters worse. We will be in a continual downward spiral.  If anyone thinks that single-payer systems works, look at our own military, VA, and tribal health services.  Cost before coverage. Coverage is not access. Access is not quality. Let's make sure the futures of those most in need are secured.  Not the futures of the special interests.

John Livingston is a retired surgeon and an adviser to the Idaho Freedom Foundation.