Here’s basically what happened: I was at a 4th of July party well on my way to having a great time, when I somehow found myself in an argument about Medicaid and the Medicaid expansion in health care reform with a few young doctors who I felt had totally eye-popping worldviews about access to health care for the poor.

At some point in this argument this hypothetical was proposed to me: “What do you do for a living? A writer? How would you like it if the government told you you had to write some specific thing. That’s what doctors have to do. They have to treat poor people in emergency rooms no matter what.”

And at that point I lost every ounce of cool I possess because this person seemed to be arguing, as a medical professional, that he would like to allow people who cannot pay for their medical care to be sick and/or die. I guess if that’s your position, I have no rebuttal. But if you’re, you know, not a psychopath you probably acknowledge that societies need ways to provide medical care for disadvantaged people—especially the elderly and disabled who cannot work and have no way to provide care for themselves.

Therefore, all the arguments about why Medicaid sucks—that it doesn’t pay doctors enough, that patients are frequently non-compliant and make poor health decisions—are all arguments for improving the program, not abandoning it.

Anyway, this is all my extended way of saying that in light of this drunken argument, and, more importantly, the Supreme Court’s take on the Medicaid expansion in the Obamacare decision, I wanted to write a big, long blog post on the topic. Instead, I got in touch with Harold Pollack, a Professor of Social Service Administration at the Center for Health Administration Studies at the University of Chicago.

Pollack has been one of the Affordable Care Act’s most passionate and eloquent advocates and has what I would describe as “occasionally uncanny” insights into the myriad ways our health care system functions (or fails to). He’s written all kinds of stuff about health care reform, but if you have to choose one, I’d go with this piece in the Washington Monthly where he games out what may happen to health reform in a Romney presidency (wow, I think I totally just outed myself as a Harold Pollack groupie). Here following is our conversation:

Markley: We’ve heard a lot about the individual mandate, but speak for a moment about the consequences of the Medicaid portion of the decision.

Pollack: The Court upheld the basic constitutionality of the Affordable Care Act. I personally believe this was an easy case that should never have gotten this far. This case did a lot of damage in just delaying the execution of health care reform. As for Medicaid, there are some serious consequences to the way the Supreme Court has limited the power of the federal government. It said the government can use carrots but not sticks, but if many states choose not to expand [Medicaid], this creates all sorts of mischief and leaves millions of people uncovered.

This is not about Barack Obama versus Mitt Romney. It’s about millions of people who are uninsured. We’ve got to get this right because it will make an enormous difference in people’s lives… I am optimistic that once the dust settles every state will take the money. This is money being offered with a 94% federal match. What people don’t seem to understand is that many of the people affected are already getting services from the public sector—from hospitals and social services agencies. Every nursing home desperately wants this expansion. The great irony is that these big red states like Texas and Florida that have huge uninsured populations—We are begging them to take free money to take care of their own citizens. But these Governors are so dug in politically and they have such a toxic attitude about health care.

If you look at the enormous fight to create Medicaid in states of the old Confederacy, within six or seven years they were all in. They desperately needed this money, and when it happened it went surprisingly smoothly.

I got into a heated exchange with a few young doctors about health care reform, and this is a phenomenon I feel like I don’t understand—the right-wing MD who’s advocating to let people be sick or die. Is the low reimbursement rate for Medicaid the entire reason?

Well, people get a lot of messages that aren’t accurate. I do think the reimbursement rate is a problem, but the ACA raises the rates for primary care providers for a while. It’s specialists that are really tough.

Take a state like Illinois--where we have serious governance problems--and our Medicaid desperately needs improvement. Audits show something like two-thirds of specialty practices won’t schedule appointments for kids on public insurance. That’s a reflection on the providers. It also reflects the market reality that Medicaid is a very poor payer and doesn’t pay in a timely way. Not to mention these patients have many challenges that make providers reluctant to deal with them. The solution, though, is not to leave people uninsured but to improve the Medicaid program. I would rather have a system where Medicaid and Medicare paid close the same rate for the same services…

The physicians that I know advocate improving Medicaid, not deciding: “My life would be easier if I ignored economically disadvantaged people”… I often hear the bad form of this argument when people identify [Medicaid’s] flaws while declining to support things that are proposed to do something about that. I’m well aware of the ways that reimbursement rates cause a problem. I take care of an adult who is developmentally disabled, and who is on Medicaid. It’s very difficult to just to find a dentist. I wished that providers worked with it better.

However, the great majority of Medicaid is spent on the elderly and disabled, and this is why the Republican governors will eventually relent: it’s one thing to beat up on welfare recipients. When you start beating up on people’s grandparents, politicians will relent. There are just too many constituencies that will be affected. When hospitals and nursing homes and individuals start saying, “Hey what’s going on here?” There will be a lot of pressure for states to embrace the Medicaid expansion in health reform.

And what if Mitt Romney wins the election?

If Romney wins, then health care will be fundamentally altered. It’s hard to overstate how important this election is. A lot of people will wait for the 2012 election to resolve things. But Romney’s plan—Governors understand that if you block grant Medicaid it imposes huge risks on them.

Wouldn’t Romney still need 60 votes to do something that drastic?

The history of health policy suggests that Democrats need 60 votes to make changes and Republicans need 50. It depends on the reconciliation process and what’s the sense of procedural norms, what the conservative caucus would be willing to do. If Romney wins a pretty convincing victory, conservatives will have a lot of momentum to make deep cuts to Medicaid. It’s big stakes, and it’s ironic because what Romney did in Massachusetts is obviously the model for the ACA.

Yeah, here’s a question that’s slightly off-topic: the Democrats and Obama pass a historic health reform bill and the Republican governor who implemented the model becomes Obama’s opponent and runs against it. Honestly, could you write a weirder story than this?

With the election of Barack Hussein Obama already you’re in improbable territory. Political scientists tell us that The Republicans have really moved right and the procedures of the congress have really slowed down what the Democrats were trying to do, and obviously the economy is so challenged. Right now if we had a 4 or 5% unemployment rate, much of what we were hearing would be noise within 25% of the public instead of 40%. There are just so many things coming to a head, including the demographic transformation of the country.

The sad thing is Democrats and Republicans actually have a lot of common ground here. Romney did a nice job in Massachusetts of creating something that was a workable plan. The Affordable Care Act—on the substance, even though it didn’t get any Republican votes—actually is the bipartisan market-based compromise on health reform. If the Republicans were to win power sometime down the line, they’d have to rename it and repackage much of it as something else.

You’ve written about how Obamacare will make a huge difference to millions of people on the ground, and I share your sentiment that the Left has been irrationally dismissive—to its own detriment—of the Affordable Care Act because it didn’t have certain elements like the public option.

First of all, I am a supporter of the public option. I believe, nonetheless, that the disillusionment with Obama is really misdirected in a destructive way. The reality was that you needed 60 senators and that included conservative Democrats. [The ACA] was a great achievement, and if you look at other things of comparable magnitude, they were passed in moments when the Democrats had dominant majorities in both houses. Even having all those votes, [the ACA] still had a heavy climb. Blaming Obama because Kent Conrad and Max Baucus and Charles Grassley had the ability to slow this down focuses attention on the wrong end of Pennsylvania Avenue.

I also think a lot of progressives don’t understand or don’t appreciate that the nuts of bolts of the ACA are just crucial to millions of people.

If I go down to 57th street, there’s the guy who’s bumming quarters there, right? Let’s suppose he has a substance abuse problem. He needs to get into a methadone program, not to mention he’s probably got a cardiovascular problem and some other health issues, too. Who will pay for that care? Right now, he’s not eligible for Medicaid because he’s not a vet, he’s not a mom, and substance abuse isn’t a disability that gains him eligibility to a federal disability program. Now with reform he can get on Medicaid because he’s poor. He can get treatment. He can get his cardiovascular problem taken care of.

This is something that your daily news reader may not think about. A lot of this stuff—the wish list for the National Multiple Sclerosis society, the advocacy arm of the American Cancer Society, getting rid of pre-existing conditions, eliminating lifetime and annual caps on insurance, requiring insurers to cover essential health benefits—was included in the nuts and bolts of health reform. That’s huge. There’s also $196 billion being used to provide health care for moderate and low-income people. This is a very important policy that now says we are responsible to make sure every American has access to affordable health care. I do regret how back-loaded it is, because once it’s on the ground people will not want it taken away.

Why was the bill so back-loaded?

The original sin of health reform… Because conservative Democrats needed direct outlays to come in at below $1 trillion. Also it takes some time to get things up and working; there are going to be so many administrative glitches when this thing comes online. We’re messing with a 2.8 trillion dollar medical economy. The real help is coming in 2014. So I’m as frustrated as anyone.

But if young progressives become disillusioned, this would be tragic. This is where you have to admire the Tea Party people who get really mad and when they don’t get their way, they don’t go home and say the political process is so messed up. They primary Republican politicians. Republicans in congress are terrified of them. I don’t think many Democratic politicians harbor the same fears of an Occupy primary challenge.