Hunger Games Politics


If a free society cannot help the many who are poor, it cannot save the few who are rich.

— John F. Kennedy, Inaugural Address

Not all of the states’ reactions to the recent health care decision by the U.S. Supreme Court are an embarrassment.  Only a select few.  Some States, like Oregon, welcomed it.

In 2008  Oregon embarked on a program to provide health care to some of its residents who live in poverty.  It did not have enough money to cover all its impoverished residents so it set up a lottery system and folks who entered it got a chance to win health insurance coverage. Unlike lotteries at charity events, this lottery didn’t cost a thing to enter.  The only requirement to participate in the lottery was that the entrant be poor and not have health insurance.  The lottery was an instant success.

In 2008, 89,284 people entered the lottery and the lucky winners received that which those who live in other wealthy, industrialized nations get without entering a lottery-health insurance.   Once the lottery had taken place its effects on those won was studied to determine the costs and benefits of the coverage.  The study disclosed that 25 per cent of the winners were less likely to be burdened by unpaid medical bills and 40% per cent less likely to find that paying medical bills forced them to skip paying other significant obligations. Those who won were more likely to have a family doctor they visited regularly and enjoyed better overall health than those who did not have insurance.

Notwithstanding the success of the lottery many residents remained uninsured and Oregon is happy to abandon the lottery in favor of having all its residents obtain insurance. Bruce Goldberg, the Oregon Health Authority director, is not worried about the additional cost to the state.  He said the Supreme Court decision is “very good news for the 600,000 Oregonians who do not have health care coverage. . . . Under the Affordable Care Act, the health care lottery for low-income Oregonians goes away and everyone wins.  That is good for them, good for their families, and good for Oregon.  They will have better health care and more financial security. . . .” If governors of some of the other states cared about the health of their citizens they would study the results of the lottery and might even decide to permit their Medicaid rolls to expand. They haven’t and they don’t.

A spokesman for South Carolina’s Gov. Nikki R. Haley, said:  “We’re not going to shove more South Carolinians [600,000 poor people without insurance] into a broken system that further ties our hands when we know the best way to find South Carolina solutions . . . is through the flexibility that block grants provide.”  Since there are no block grants available, if South Carolina fails to take advantage of the ability to expand eligibility, 600,000 poor South Carolinians will remain uninsured.

Governor David Heineman of Nebraska explains his opposition to  expanding Medicaid eligibility explaining that if it is expanded it will affect state aid to education even though the federal government will pay all the cost of the increased costs of expanding Medicaid until 2017 and by  gradually decreasing amounts  until 2020 when states will have to assume 10% of the cost with the federal government paying the remaining 90%.  Another Governor who is unambiguous in his response is Florida’s governor, Rick Scott.

Governor Scott has said that: “Florida will opt out of spending approximately $1.89 billion more taxpayer dollars required to implement a massive entitlement expansion of the Medicaid program.”  Explaining his decision the governor said:  “Floridians are interested in jobs and economic growth, a quality education for their children and keeping the cost of living low.  Neither of these provisions (Medicaid expansion and insurance exchanges) will achieve those goals, and since Florida is legally allowed to opt out, that’s the right decision for our citizens.” Twenty percent of Florida’s residents lack health insurance.  Mr. Scott is not among them.  The state provides health insurance for him. If Florida took advantage of the expansion 1 million residents would get coverage.

Health insurance seems like a luxury only to those who have it, people like Governors Haley,  Heineman and Scott.  Since they  refuse to take advantage of Medicaid expansion the law permits and largely funds, to help their impoverished citizens, perhaps they would consider starting a lottery.  Oregon did cover it in an impartial manner as many people as limited funds would permit.  The recalcitrant governors could do it to give the impression that they were doing something positive for their poor citizens even though they were doing far less than the law permits.  Watching to see who won the lottery and, therefore, obtained health insurance, could be a source of amusement for observers who already have insurance and would give the uninsured but hopeful poor a distraction to take their minds of the other hardships poverty forces them to endure. Kind of like Hunger Games.

Christopher Brauchli is an attorney living in Boulder, Colorado. He can be emailed at brauchli.56@post.harvard.edu


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