The Affordable Care Act (ACA), a.k.a. Obamacare, is starting to kick into gear and states are having to make decisions about how they are going to participate. Here in North Carolina the state legislature is considering opting-out of the expansion of Medicaid called for by the ACA:

Legislation is moving forward in the General Assembly to opt out of the Medicaid expansion under the Affordable Care Act. The expansion would provide health insurance to people living in households with incomes below 133 percent of the poverty line. The federal government would cover 100 percent of the costs for the first three years and 90 percent of the costs thereafter.

Besides extending coverage to about 400,000 poor NC residents who wouldn't get health insurance otherwise, the expansion would bring in $40 billion on net (about $50 billion in total spending), which would jolt the economy and create jobs.

A new report by Regional Economic Models, Inc. forecasts that the expansion would add nearly 6,000 jobs to the NC economy in the first year of the expansion, as participation in Medicaid starts to grow, and 20,000 to 25,000 jobs in subsequent years, as participation stabilizes at a higher level.

It's no secret, or a surprise, that the newly empowered Republican majority in the NC legislature is opposed to the ACA. Most conservatives I've talked to would like to see entitlements of all varieties cut rather than expanded, and if you avoid getting all hot and bothered and really listen to them you realize it's not out of meanness. Many of them truly believe that we're robbing an entire generation of any incentive to improve their own lot. Most I've talked to absolutely believe we should help the truly helpless, but defining who the truly helpless are and determining how best to help them can get you into some heated debates faster than you can say Obamacare.

On the flip side most liberals I know truly believe that as a society it's in our best interest to make sure that all people have access to good health care. Most I've talked to view it as a moral issue – we should do it because it's right. 

Here's where I get frustrated: I think there's a middle ground between the two groups. I too think there's a moral obligation to do everything we can to make sure all members of our society have access to health care, but I also think there's a solid "business case" to be made for it. A healthy society by definition will be more efficient than a sick society, and the resources tied up in caring for very sick people could be better spent elsewhere.

Put simply sick people have a hard time working or contributing to society in a meaningful way, and if you want to institute reforms in other areas of our entitlement programs – for instance requiring X hours of community service in return for Y dollars of aid – then you need to make sure they are healthy at a bare minimum. We can debate the details all day long, but in terms of priorities I don't know how you can put health care anywhere below the very top tier.