The Affordable Care Act’s Medicaid expansion is unpopular. Democracy is the idea that government should not do things voters do not support. If voters supported the taxes necessary to fund the Medicaid expansion, states would have enacted and paid for it themselves without the feds picking up 90 percent of the cost. If voters nationwide supported Medicaid expansion, Congress would not have to borrow money to pay for it. If voters do not want to pay for something, it is not popular.

It is dangerous to the poor. Congress cannot keep borrowing money forever. The Congressional Budget Office projects that by the end of 2020, the federal debt will exceed the size of the U.S. economy. When, inevitably, Congress hits a borrowing constraint, it will cut spending. First on the chopping block will be the Medicaid expansion, because it was never popular in the first place. Expanding Medicaid means putting millions of necks on that chopping block.

The ACA’s Medicaid expansion favors the able-bodied over the truly needy. The Medicaid expansion encourages states to provide better care for able-bodied childless adults and to cut services for expectant mothers, children and the elderly.

Expanding Medicaid would discourage the pursuit of better, lower-cost ways of delivering care to its target populations. Coverage does not equal access. Nor does it equal quality. Government-provided coverage locks in existing delivery systems and stifles innovation. It took an international crisis for providers to discover the benefits of telemedicine, largely because Medicare and Medicaid do not innovate.

If voters supported the taxes necessary to fund the Medicaid expansion, states would have enacted and paid for it themselves without the feds picking up 90 percent of the cost.

Any program that spends hundreds of billions of dollars will benefit somebody. Persuasive research finds an association between Medicaid coverage and neonatal outcomes, for example. But if the Medicaid expansion delivers health improvements, it is only within the confines of, and without reforming, a system that is extremely expensive and often provides dangerously low-quality care.

Making coverage and care better for low-income Americans requires taking on the special interests that have made the U.S. health care sector so expensive — including government itself. It requires making permanent and expanding the recent bipartisan actions by governors to eliminate protectionist barriers to care. Expanding Medicaid just throws more money at the special interests that caused the problem.

Reform will not be easy. But no matter what Medicaid-expansion advocates or other snake-oil salesmen say, health reform never is.