On December 14, former Secretary of the Department of Health and Human Services Kathleen Sebelius made news by calling the decisions of Kansas and Missouri to turn down the Medicaid expansion contained in the Affordable Care Act “morally repugnant and economically stupid.”

Heated political rhetoric does not alter the fact that a state’s decision to expand Medicaid involves complicated tradeoffs.

According to the Organization for Economic Cooperation and Development (OECD), the United States spends $8,713 per person on health care — more than double the OECD average.  But under ObamaCare, that high level of spending isn’t buying the best care. The law’s numerous regulations and intrusions have simply inflated the nation’s healthcare tab — without actually improving the quality of care available to patients. The US has long spent more than other nations on care. ObamaCare has just accelerated that trend, despite the law’s goal of reducing health spending. Last year, health expenditures jumped 5.3%, up from an average of 3.9% over the previous six years, according to data from the Centers for Medicare and Medicaid Services.

Instead of more federal regulation and subsidies, what U.S. health care needs is adoption of market principles, starting with broad empowerment of the patient-consumer. The proposals advanced in this volume would replace many counterproductive and outdated federal policies with practical, market-based reforms that aim to provide all Americans with access to high-quality health care at affordable prices.

ObamaCare is performing worse than expected when it became law: plans are less attractive, enrollment is lower, premium increases are higher, and risk pools are sicker. Medicaid expansion is a key problem with the law. The main problem with Medicaid, which existed before the ACA took effect, is that enrollees receive little value from the program. The joint federal-state health care program needs large scale reform so that it provides better value for both enrollees and taxpayers.

States increased their spending in fiscal year 2015 by the biggest margin in more than 20 years, but most of the increase was thanks to huge leaps in Medicaid spending under the first full year of the Affordable Care Act. Spending increased last fiscal year, which ended on June 30 for most states, by 7.8 percent, according to new estimates from the National Association of State Budget Officers (NASBO).

Whether it is the Centers for Medicare and Medicaid Services (CMS) determining which treatments and technologies are worth covering and how much they are willing to reimburse for them; the Agency for Healthcare Research and Quality (AHRQ) mandating quality and safety standards; or the new Affordable Care Act exchanges setting the standard for benefit packages throughout the health insurance market, it is clear that government agencies and their mandates play a powerful role in guiding the provision of health benefits and the overall construct of the market.

Michael Cannon of the Cato Institute, Tarren Bragdon of the Foundation for Government Accountability, and Daniel Landon of the Missouri Hospital Association joined former Secretary of the Department of Health & Human Services (HHS) Kathleen Sebelius to discuss Medicaid expansion under the Affordable Care Act.

Complete footage of the debate is available here: Part 1Part 2Part 3Part 4Part 5, and Part 6.

One of the untold elements of the rapid decay underway in the ObamaCare exchanges is the massive shift toward the Medicaid managed care companies, and away from the traditional commercial insurers like UnitedHealth Group and Aetna. In short order, ObamaCare is evolving into a Medicaid marketplace. Not only in terms of the design and quality of the narrow-network plans that are being offered, but in the actual carriers that sell those policies.

Advocates in Washington of the Affordable Care Act have been fighting tooth and nail to preserve the president’s signature health-care law—and they’re fighting even harder to expand it in the states. Conservative lawmakers in our home states of Utah and Florida recently defeated a combined three proposals to expand Medicaid under ObamaCare. They were absolutely right to do so, as the fiscal messes in states that did expand Medicaid demonstrate.

“Everyday people with good health insurance and ready access to medical care die of preventable diseases,” my friend John, a retired surgeon, wrote me recently. My friend was lamenting a recent article appearing in many Idaho newspapers about the tragic death of a woman with asthma. Her death was blamed on lawmakers who have refused to expand government-run programs like Medicaid to include able-bodied, childless adults.