In Paul Krugman’s June 9 commentary titled “The GOP’s unhealthy spite,” he asserts that opposition to the Affordable Care Act (ACA or Obamacare) is based on spite and disregard for the poor.

That is a specious argument. Republicans (and a growing number of Democrats) oppose the plan for exactly the opposite reason, and that is the belief that the ACA pushes us inevitably toward a fully government-run health care bureaucracy, so regulated and controlled that the strengths and quality of our system will be degraded for everyone, including those in the most precarious situations.

Medicaid, he states, provides health coverage to very low-income Americans “at a cost private insurers can’t match. ... So the ACA sensibly relies on expansion of Medicaid to guarantee care to the poor and near poor.”

Rather than sensible, this is actually senseless. Because Medicaid pays exceedingly low fees to care providers, and as states have pushed reimbursement levels well below the actual costs of caring for Medicaid patients, many doctors have significantly restricted the number of Medicaid patients they will see.

Additionally, recent evidence shows that the quality of care received by Medicaid patients is sub-par and their outcomes, all other variables being equal, are worse than those for patients covered by commercial insurance.

The overall result is often a lack of accessible quality health care, precisely what the program is supposed to provide.

Finally, since Medicaid is not tied to our employment-based system of insurance (it is a welfare program) it actually discourages people from finding better paying jobs.

A working person might lose his Medicaid insurance without being offered insurance through his place of employment, resulting in a net reduction in his overall financial well-being.

This is unfair to anyone who desires a better station in life. The ACA doubles down on this existing, flawed program by massively expanding the number of enrollees instead of reforming it.

Krugman rails against those politicians and states they are in favor of rejecting the expansion of Medicaid and the accompanying federal funding as a cynical, conscious effort to “hurt the poor.”

This is ridiculous. Rejecting the short-term benefit of millions of federal dollars to accept the expansion of Medicaid is financially sound in the long run without true reform of the system.

Hospitals, which are clamoring for the funds, need to accept the fact that Obamacare will not solve their financial woes. Even with the expansion dollars, cuts in Medicare are going to cause problems anyway.

My proposal would be for any state that opts out of the Medicaid expansion, as envisioned in the ACA, to get the dollar equivalent of the federal spending that would have occurred in the form of a health care block grant to the state, to be used at the state’s discretion, to improve health services and health care for low income populations.

That is, South Carolina’s share of the money should be returned to South Carolina for us to decide how to use.

I, and every physician I know, want all Americans, including the poor, to have secure, stable access to affordable high-quality health care. The ACA (Obamacare) is the wrong way to achieve universal coverage.

Saying “no” leaves open the possibility that America and the states can go in a different, more market-oriented direction with a different plan.

That plan would have to make real reforms, not just reshuffle the deck hoping for a better outcome.

Mr. Krugman’s opinion is unhealthy to the debate.

Marcelo Hochman, M.D.

Henry Tecklenburg Drive

Charleston