There are only two sorts of people roaming this earth: those who just want to be let alone and those who simply cannot keep their hands to themselves.  We institute governments to restrain the latter from tormenting the former without relent.  Nowhere is the intrusive impulse of the nanny-stater more prominently featured than in the issue of Medicaid expansion.

Medicaid expansion is the bad idea that will not go away.  An integral leg of the Obamacare stool, it was intended to the do the heavy lifting for the promised result of universal health insurance coverage.  Those Americans who could not be enticed to buy health insurance with wildly generous subsidy offers would then be coerced into doing so under penalty of fine.  The remaining uninsured population would be caught in the expanded Medicaid net, ostensibly achieving universal, albeit unsustainable, coverage.

However, the Supreme Court ruled expansion to be voluntary for states, and despite federal offers of mega-dollars, many states wisely avoided this boondoggle.  Nebraska was one such state.

For the next six years, Nebraska lawmakers voted down bills to expand Medicaid in our state.  This year, funded almost entirely from out of state, with Washington, D.C. lobbyist money, the proponents launched a petition drive to put the expansion question on the November ballot.  The question is now up to the voters.

In selling their scheme, many proponents of expansion have found honesty to be a dreadful handicap and promptly abandoned it.  They claim that 90,000 Nebraskans are in the so-called "coverage gap," defined as earning too much to get subsidies but not enough to afford insurance without subsidy.

However, the Kaiser Family Foundation (KFF), a favored think-tank of the left, looked at the uninsured populations for each state and helpfully broke down the demographics by eligibility.

KFF estimates that there are 130,000 individuals involved in Nebraska, not 90,000, which by itself throws off the revenue projections cited by advocates.  But what is the status of these 130,000, really?

According to KFF, 14% of these are already eligible for Medicaid under existing rules.  Another 39% qualify for free or heavily discounted premiums via subsidy on the insurance exchanges already.  Thirty-four percent make enough to purchase health insurance without subsidy, are eligible for insurance through their employers, or are ineligible due to immigration status.

This leaves only 12% in the "coverage gap."  Fewer than 16,000 people.

Even the remaining "gap" population has access to new policy offerings from Medica, Nebraska's sole remaining ACA insurer, designed especially for them.  Having been freed by President Trump from the ridiculous mandatory coverage minimums installed by his predecessor (such as maternity care for men), the free market saw a need and stepped in to meet it.  How shocking.

By the left's own sources, using the left's own standards, Medicaid expansion is unnecessary – unless your intention isn't helping people, but rather helping yourself to a fat payday and endless voter dependency.

Once the expanded population is added to the existing Medicaid population, nearly one in three Nebraskans will be on Medicaid.  That eye-popping number doesn't include the tens of thousands of folks who currently have policies through their employers who will be unceremoniously dumped onto Medicaid once the businesses realize they no longer need to maintain that expensive benefit, since the bulk of their employees qualify for government insurance.

The allure of Medicaid expansion is its promise of federal dollars to help pay.  As proposed, the federal government will reimburse the state 90 cents for every dollar spent on the care of the new expansion enrollees.  This compares quite favorably to the 53-cent rate on current Medicaid recipients.  But the devil is in the details.

Nebraska is a managed care state, meaning that rather than the Medicaid patient seeing his doctor and the doctor sending the state the bill for services and treatments, Nebraska has chosen to hire a company to whom it pays a flat amount monthly for each enrollee.  The managed care company pays the claims, hopefully making a profit by the time all is said and done.

However, when these new enrollees come in from expansion, they are an entirely different demographic from the current recipients upon whom the monthly rate is based.  Unlike the current recipients, nine out of ten folks in this new group, according to the Urban Institute, are healthy, able-bodied adults without children, between the ages of 19 and 54.  Literally, the demographic that is the least expensive to insure.

This means the managed care company will reap a tremendous windfall, as it will be paid the same freight for the new as for the old, yet the new will require far less expense and bring far higher rates of reimbursement.  One managed care company in California saw a 576% increase in profit in the first two years of expansion alone.  Consider also that in every state that has adopted expansion, current recipients (who are reimbursed at far lower rates) have been shuffled onto waiting lists for services to make room for the new, better paying enrollees.

Having gained overgenerous payments for covering new enrollees, the managed care company will now reduce its costs dramatically at the same time by paying far fewer claims for its original clients, who, according to an exhaustive accounting by the Federal Government Accountability Foundation, are now dying by the thousands while on waiting lists spawned by expansion.

It doesn't stop there.  Our private insurance premiums will increase as well when hospitals, clinics, and providers raise their rates, ostensibly to offset the lost revenue from accepting more Medicaid patients and fewer higher paying privately insured patients, despite the lack of actual claims.  This has been the experience in every state that has adopted expansion.

Like private insurers, hospitals, clinics, and providers can base future prices (and premiums) on projections, and you can be assured the insurers will project a need based on current recipients' usage rates, not the actual rates of the new recipients, which will be far lower.

Are you beginning to understand why some self-described Republicans are supporting this at the behest of their medical and insurance industry donors?

Nebraska will be obligated to maintain these needlessly inflated rates due to the provision in expansion's enabling legislation that establishes the inflated rates as the floor in a building with no ceiling.

The tired and shopworn talking points of previous years have been dusted off to convince Nebraskans that spending $100 million in the hopes of getting $90 million back is somehow "economic activity" for our state and that failing to shoulder this unending obligation means that someone else will be getting all our money! 

Despite being peddled as Medicaid expansion under the Affordable Care Act, (ACA) Nebraska's ballot initiative is a thing apart, boasting a legal structure that is nothing short of a bill of indentured servitude for the citizens of Nebraska – a point that has been shielded from public view, hidden like a crazy aunt in the attic, to avoid disturbing the guests.

Under the ACA, a state may withdraw from Medicaid expansion.  States are also given the flexibility to adjust coverages, to fine-tune eligibility requirements for the expansion population, and to otherwise tweak and alter the program to suit the fiscal realities and medical necessities of their states. 

Proponents of expansion in Nebraska have been citing this flexibility as a failsafe should expansion critics be proven correct in predicting fiscal catastrophe.  This is a lie.

In the enabling legislation for Nebraska's Medicaid Expansion, in addition to numerous poison pills designed to ensure that the state can never reduce coverage, alter eligibility, or reduce services, there is paragraph 5, and it delivers the killing blow.

(5) This section shall apply notwithstanding any other provision of law or federal waiver.

The ACA came within one vote of repeal earlier this year, and Majority Leader Mitch McConnell has already made clear his intention to take that vote again after the seating of new senators following the midterms.  The chances that the federal government will maintain the overgenerous promises made under that failed program are nil. 

The ACA and Medicaid expansion are going away, but that won't matter in Nebraska.  We will have chained ourselves to an error – condemned to march in endless circles to grind the flour our politicians will dole out to buy votes.  This program will become the lash by which the left will whip the rest of us into submission. 

When Nebraska voters see the question, "Should Nebraska expand Medicaid?," it should more accurately be read as "Should Nebraska take the health care the profoundly disabled, elderly poor and blind rely on to survive, and instead give it to the young, healthy, and able-bodied in the hopes of buying votes and making campaign donors fabulously wealthy with our tax dollars?"

That is the true question we face in November.  Our answer will be to our credit or to our eternal shame.

The author writes from Omaha, Nebraska and welcomes visitors to his website, www.dailyherring.com.  A commercial-free broadcast of a radio show covering Medicaid Expansion, hosted by the author is available here.