Somebody has to pay for Medicaid

Under the Affordable Care Act, Medicaid stakes are high. And debate around the issue in South Carolina is likely to be heated and involved.

It should be.

The ACA calls for expanding Medicaid to cover more people. In South Carolina, estimates of additional people getting coverage range from 350,000 to 510,000. While the federal government pays for the vast majority of the cost, the state ultimately will have to cough up its own portion — as much as $2 billion total by the year 2020. To put that in context, this year’s budget is $6.8 billion.

Gov. Nikki Haley has said she will forgo the $13 billion in federal Medicaid funds because accepting it would drain state resources, which already are strained even before any Medicaid expansion might occur.

You can’t get blood out of a turnip.

But commercial health care interests say that would be a kick in the teeth to an industry already in line for cuts under the ACA. And that means hospitals will charge more, and employers, insurers and the insured will pay more. The industry anticipated the Medicaid expansion to offset some of the losses it faces.

S.C. Medicaid Director Tony Keck, a Haley appointee, agrees with her that the system is broken, But he is looking for a solution. He said he plans to negotiate with federal counterparts for alternatives, if the governor is able to opt out of the expansion program.

Mr. Keck on Tuesday also invited those in the health care industry to be part of what promises to be a fierce debate on the subject when it is taken up by the General Assembly next year. To fail to make their case would be a mistake.

For example, beyond serving a population in need of heatlh care, they say the expansion would mean a growth in well-paying jobs. Health care representatives say the governor is failing to recognize theirs as a growing industry that deserves consideration as she seeks jobs, jobs, jobs.

Mr. Keck seems confident in his stance, which is in line with Gov. Haley’s. But he said Tuesday, “When you put a lot of heads around the table, you can do better analysis” — even if all the discussion does is reveal what the disagreements are.

Too many people can’t afford medical care, but there are limits to how much health care the government can afford to provide. South Carolina’s tough decisions must be made with eyes wide open to their financial ramifications.