If I were to design a course on leadership today, I could ask my students to ponder the art of war or seven habits of highly effective people, exhort them to go from good to great or to assemble a team of rivals, even urge them to hone their abilities to win friends and influence people.
This syllabus would teach them about many of the key qualities of any leader: the courage to make unpopular decisions, the focus on achieving measurable results, and the compassion and humility to ask no more from the least of your followers than you are willing to commit yourself.
Or I could just ask them to consider a timely case study: the contemporary Republican governor. Operating at the stress point where politics meets practice, the 30 Republican governors today face a series of choices that are all about leadership.
Chapter one in this case study: the implementation of the Affordable Care Act, or Obamacare. Exhibit one: the Medicaid expansion.
This is the part of Obamacare where states are supposed to extend eligibility for their Medicaid programs to anyone making less than 138 percent of the federal poverty level -- roughly $27,000 a year for a family of three. Right now states' Medicaid programs only cover low-income people who fall into certain categories (e.g., pregnant women, working parents, people with disabilities), and often only the very, very low-income. In the median state today, a working parent in a family of three loses Medicaid eligibility when her annual income tops $12,000, or 63 percent of the federal poverty guidelines.
The Supreme Court decision upholding the constitutionality of Obamacare said that states could not be forced to implement the expansion. Which brings us to the leadership choice: do you help your people or help your party?
This shouldn't be a close call. Consider:
- The expansion is free for the first three years (and then really cheap): The federal government will fully fund Medicaid services for the Medicaid expansion population until 2017, and it will never fund less than 90 percent of the coverage.
- It's returnable: As with the existing Medicaid program, states can drop the expansion at any time.
- It's beneficial: There are millions of people -- an estimated 17 million nationwide, or 1 million in Florida alone -- who could, thanks to the expansion, receive health care coverage for the first time.
- It saves money: More coverage means fewer emergency room visits by the uninsured -- an expense that ran state and local governments $10.6 billion in 2008.
- You're already paying for it: whether your state adopts the expansion or not, everyone's tax dollars fund Medicaid.
But if your party's recent presidential candidate ran on a platform of repealing Obamacare, or you were one of 26 governors to ask the Supreme Court to find the law unconstitutional, then taking the expansion funds feels a bit like ... well, eating crow.
Happily, there are some Republican governors who are capable of rising above disappointment. So far eight -- including Florida's Rick Scott, New Jersey's Chris Christie, Ohio's John Kasich, and New Mexico's Susana Martinez -- have announced that they will expand their state's Medicaid program. In Governor Scott's words, it was the right thing to do for "the poorest and the weakest" in the states.
Unfortunately, there are also governors who seem bound to cut off their collective nose to spite their face. Seventeen states plan to reject the Medicaid expansion, leaving their low-income citizens without access to basic health care.
Worse, some states are pulling back on the Medicaid coverage they already offer. Earlier this year, Maine informed thousands of seniors that they face imminent loss of Medicaid funds that help supplement gaps in Medicare coverage. Without the funds provided by Medicaid, many of these Mainers will not be able to pay for necessary health care -- things like hospital stays, chemotherapy, diagnostic tests, and prescriptions.
Maine Governor Paul LePage apparently did not get Governor Scott's "poorest and weakest" memo. Many, if not most, of those affected by the cuts in Maine are elderly people with disabilities who make so little money that they turn to Medicaid to help cover premiums and other gaps in their Medicare coverage. These are not the people on whose backs a state budget should be balanced. (Because the ACA explicitly forbade states from cutting Medicaid enrollees who are pregnant or have disabilities, we also think it is illegal, and NHeLP has joined a class action lawsuit to stop the cuts.)
Republican governors who expand Medicaid may not win popularity contests in their own party -- Chris Christie was pointedly not invited to the Conservative Political Action Conference this year -- but I have to imagine they sleep better and walk taller.
And that is leadership.