Note the very first idea conveyed in this intro: The GOP wants to thwart Obamacare and make it the top issue in the mid-term elections. That's the focus of this story? That's the number-one idea in the lede? The story's material about Medicaid expansion under the Affordable Care Act in the state of Michigan is just incidental fluff, I guess.

For NPR reporters and editors, everything about the ACA revolves around Republicans and their post-ACA behavior, with special emphasis on the politics of the upcoming mid-term elections. They seem compelled to bring up Republicans and their own take on Republican politics in any news story about the ACA, despite the fact that there are many, many other aspects about the ACA that need exposure; however, virtually all of those other aspects would make Obama and the Democrats look bad, so draw your own conclusions about that.

On the other hand, I'm glad to see that NPR has changed its tone a bit regarding how much of the cost of Medicaid expansion will be paid by the federal government. The intro indicates the feds will cover "a majority" of the costs, instead of 100% of the costs in the initial years, as has been reported previously.

We have no reason to doubt these dollar figures quoted by Ms. Schlichting. However, they don't tell the whole story. Whitney failed to inform listeners that states and the federal government have programs to compensate hospitals for their losses in providing uncompensated care.

For example, the federal Disproportionate Share Hospital program (or DSH program, pronounced "dish") pays-out such funding for hospitals that provide a disproportionately high amount of charity and Medicaid care, in order to compensate them for their losses. In federal fiscal year 2011, Michigan's total DSH expenditures were $387.9 million, including federal and state dollars, and in federal fiscal year 2014 (when this NPR story aired), the federal government has allotted $282.6 million in DSH funds for Michigan, not including state dollars.

Whitney didn't tell us about these sorts of programs for some reason. I wonder if that's because it would diminish the point he was trying to make.

Not exactly. The ACA did not  "offer" Michigan or any state "the chance" to expand Medicaid. The law, as written, requires states to either expand Medicaid or exit the program altogether. The U.S. Supreme Court ruled that requirement to be an unconstitutional coersion, and that ruling rendered the expansion optional for states.

That whole dynamic is lost when Whitney frames it as the ACA "offering" states "the chance" to expand Medicaid. The expansion was "offered" in much the same way the IRS "offers" you the chance to pay your taxes.

Also, people receiving Medicaid benefits do not and will not "pay their hospital bills." The Medicaid program pays their hospital bills. To the extent that some enrollees might owe copays under Michigan's expanded program, Medicaid will not help people pay for those.

There are no sound bites from any Republicans describing themselves as "turning their backs" on anything. Instead, Whitney picked up that image from an advocate for Medicaid expansion and used it to describe how Republicans view themselves. If Republicans actually view themselves in such a negative sense, why didn't Whitney let us hear it? Maybe because it was more convenient for Whitney to just paint Republicans' self-image that way on his own. Not exactly a positive image, is it?

I have already debunked this notion that taxpayers in non-expansion states will automatically pay for Medicaid expansion in other states. (See here.) NPR used that notion once again in this story. How many more times will NPR perpetuate that theory without explaining that it just doesn't work that way in a practical sense? Just because the reporter attributes that theory to someone else does not absolve the reporter of the duty to reflect reality.

Whitney does nothing to explain that it really doesn't matter whether a state has "privatized" its Medicaid program by employing managed care. Managed care has virtually no bearing on the fiscal and practical realities involved in whether Medicaid expansion is a good idea for any particular state.

Whitney is apparently not only a reporter, but he's also achieved a level of expertise in election prognostication that qualifies him to tell us that Pscholka's "tea party" opponent is a "longshot." Is this opinion espoused by Whitney based on something other than his own personal impression? We don't know, because he didn't tell us, but he did make sure to plant the idea in our heads that a "tea party candidate" doesn't have much chance of winning.

UPDATE #1: (January 27, 2014) After writing this critique, I decided to look-up Pscholka's challenger at the Michigan Department of State's web site. She is Cindy Duran, a registered nurse claiming to have first-hand knowledge of the Medicaid system. See her web site here.

By the way, I can find nothing on Duran's web site relating to any tea party or tea parties. In a video on the site, she says she supports a Republican party devoted to conservative principles. Aren't all Republicans supposed to feel that way? The only sources I can find that call her a "tea party candidate" are news media web sites, now that they've done their best to make a dirty word out of "tea party." – All right, yes, maybe she is a longshot. Most challengers facing incumbents are longshots. However, Whitney shouldn't give his opinion about that. He's supposed to be an impartial reporter, not an expert witness.

UPDATE #2: (August 22, 2014) Pscholka defeated Duran in Michigan's August 2014 primaries.

Wait a minute. Didn't Whitney tell us earlier in the story that hospitals have been suffering under the burden of providing all this uncompensated care "for free"? Now Whitney plays a sound bite telling us that the costs of uncompensated care are being built into the premiums for private insurance coverage.

So, is Henry Ford Hospital providing $240 million per year in uncompensated care, or is Cynthia Kay's video production company "paying for all the people who are using the emergency room as their primary care physician" by paying higher premiums? You can't have it both ways, Mr. Whitney.

So, advocates for the poor are thrilled. What do people opposed to the expansion have to say? Why were they opposed? The bill passed the Michigan Senate by only one vote, according to Whitney. Why was it so close? There must be at least a few compelling arguments in opposition to expansion. Why did Whitney choose not to give us any of that?

To say they're required to pay for "at least" part of their care implies that they might have to pay for all of their care. I'm not sure why Whitney threw "at least" into the mix. It would have been more accurate and precise to say Republicans sought requirements for Medicaid enrollees to pay for "part of their care" instead of "at least part of their care."

Whitney had been describing the "compromise" in a positive light up to this point, but with this quote from Hudson, he goes off on a negative tangent. Let's look at it more closely... The White House "compromised" by allowing Republicans to impose cost-sharing on Michigan's new Medicaid recipients, but cost-sharing is a barrier to people receiving care...

Oh, wait – now I see. The only way the White House could convince Michigan Republicans to expand Medicaid was to allow Republicans to set up barriers to care. Now I understand this part of the story – Republicans are heartless bastards who don't really want poor people to receive health care! Now I get it!

Two important points need to be made here regarding "compromise" and cost-sharing:

1. The idea of cost-sharing for the ACA's Medicaid expansion is not new – cost-sharing is built into the law. As you can see on page 4 of this issue brief by the Kaiser Family Foundation, the ACA provides that states may charge premiums, deductibles, copayments, or coinsurance for newly-eligible adults under Medicaid expansion, based on a number of parameters, and also may deny services because of non-payment in some circumstances.

   So, Whitney's implication that the White House magnanimously compromised on these parameters is a bit of a stretch and perhaps a bit disingenuous. And, even though cost-sharing is built into the ACA – which was enacted solely by Democrats – Whitney makes cost-sharing seem like a 100% Republican idea, then he points out how bad cost-sharing is because it creates barriers for poor people. Oh, those horrible Republicans and their horrible cost-sharing!

2. One more thing about the White House's involvement in this "compromise," as described by both Montagne in the intro and Whitney in the story. Michigan had to apply for and be granted what's called a "waiver" in order to implement Medicaid expansion the way it has. States have been granted scores of Medicaid waivers over the years. States may apply for waivers from the federal Centers for Medicare & Medicaid Services (CMS), which is the part of the Department of Health and Human Services that oversees the Medicaid program nationwide. Waiver applications typically undergo thorough review by CMS bureaucrats at the rank-and-file level before either being approved or denied by CMS, not by the White House. They rarely rise to the level of the White House stepping in to negotiate and/or "compromise."

   Does anyone else find it odd that the White House would get involved at such a nitty-gritty level with one state's waiver application but would not know anything ahead of time about the Obamacare web site being a disaster waiting to happen? This White House that negotiated and compromised on the intricate details of Michigan's Medicaid waiver – this is the same White House that knew nothing about the IRS unfairly targeting conservative groups prior to and after the 2012 election? This is the same White House?

   Just wondering, because Whitney seems to take that for granted. We don't know for sure, but I suspect that the White House had very little, if any, involvement with Michigan's waiver application. Whitney, on the other hand, makes it sound like "the White House" compromised with Michigan Republicans directly, thereby making the White House look reasonable and open-minded when it comes to the ACA and dealing with Republicans.

Lastly, Whitney closes his story by pointing-out the thoughts and hopes of groups that favor Medicaid expansion. What are groups that oppose expansion thinking and hoping? Whitney gives us nothing about that. Without any balance along those lines, this story tends to become more of a public relations piece in favor of Medicaid expansion – with a subtle yet strong slice of Republican-bashing – rather than an actual news story.