A cornerstone of the health coverage reforms in the 2010
Affordable Care Act (ACA) was the expansion of Medicaid to a large population
currently ineligible for this benefit. This was intended to cover those who
work but have low wage jobs that neither offer health insurance nor sufficient
pay to buy health insurance on the private market. (This latter is, in itself,
a a very large obstacle; most people in “high-wage” jobs – considered by the Department of Labor
to be above about $45,000 a year -- would have great difficulty paying for
private health insurance.) In most states, Medicaid covers two populations:
children in very poor families and their mothers (in general, if there is a
father in the home, the family is not eligible) and poor people in nursing
homes (who may well not have been poor until they spent time in a nursing
home). Although the first group is much larger, the latter costs much more
money because the health care services that they require are so much greater.
The standards for income eligibility vary from state to
state, but in many states, including Kansas and Missouri (the states on either
side of the Kansas City metropolitan area) it is well below the poverty level.
Childless adults, unless they qualify for physical or mental disability, are
rarely eligible for Medicaid no matter how poor. Medicaid is a federal/state
shared program; depending upon mean state income, the federal government pays
60-80% of the cost. In order to make expansion more acceptable to many states
that are already financially strapped, ACA provides for the federal government
to pay 100% of the cost of the expansion for the first 3 years, and 90%
thereafter. But, nonetheless, this expansion is in jeopardy in many states,
because, essentially, the governor, legislative leaders, or both, oppose having
the government insure most people. The decision by the Supreme Court that
upheld ACA struck down the plan to pull all
Medicaid funding from states that did not opt for expansion, thus seriously
weakening the leverage that the federal government has to encourage it.
“Paul Nelson works for
$10 an hour at a Kansas City car shop, suffers from diabetes and can’t afford
the medicine to deal with it,” write Steve Kraske and Jason Hancock in the Kansas City Star, April 27, 2013. In “Nixon’s
pleas for Medicaid expansion go unheeded”, they describe how “The working father still earns too much to
be eligible for Missouri’s Medicaid program. That’s why he was hoping — praying
may be a better word — for an expansion of the program this year so that he
could get health coverage.” Nelson is the kind of person who might benefit
from Medicaid expansion, but is probably not going to get it because the
Republican-controlled Missouri legislature is so opposed to expansion, despite
the strong lobbying efforts of Democratic Governor Jay Nixon, who “…displayed more gusto for the cause than
any issue since he became governor in 2009…” is now regarded as “…dead, buried, gone.” Nixon had considered the federally-funded
expansion a “no-brainer”, and the fact that “An
early February poll by American Viewpoint, which usually surveys for Republicans, found that voters backed
expansion by 56-35 percent once they heard ‘a balanced set of arguments for
and against the proposal,’” has not swayed the legislature.
In Kansas, Republican governor Sam Brownback has been
playing it close to the vest regarding this issue, but Kansas legislative
leaders are very strongly opposed to expansion. Brownback engineered the
elimination of any opposition to his very conservative policies by running
opponents to “moderate” GOP senators (the House was already in the control of
the far right) in the 2012 primaries. With major funding from the Koch brothers,
abetted by the traditionally low and skewed-to-the-base turnout in primaries,
almost all were victorious; even the President of the Senate, Steve Morris, a
rancher from far southwestern Kansas, was defeated by a young and inexperienced,
but well-financed, challenger. On one issue, funding for higher education, Brownback
is currently staking himself out as a relative moderate, compared to
legislative leaders, as he is opposing the cuts that they have proposed. If
perhaps a bit suspect, since not only did he engineer their victories but his
prior budgets have significantly cut higher education, it could potentially
signal a willingness to do something similar with Medicaid.
Meanwhile, as the continuation headline for the Star article, “Obama’s switch hurt efforts here”, makes clear, the administration
has added its own disincentive to that of the Supreme Court by backing off on
cutting Disproportionate Share (DSH) payments to hospitals that take care of a
high percentage of Medicaid and uninsured patients. This weakened the
commitment of hospitals and their agents, the state hospital associations (and,
even more the Chambers of Commerce, which never really support publicly-funded
health insurance expansion in any form) to supporting Medicaid expansion. Most
still do, though, because they have been counting on expansion of Medicaid to
increase their revenue from patients (like, say, Paul Nelson) who were
previously uninsured and make up for cuts in Medicare payments, which are
already taking place.
But much more important than the financial interests of
hospitals or doctors, much more important than the posturing of politicians, is
the impact on actual people. Paul Nelson is one person, but there are hundreds
of thousands of people in his position in Kansas and Missouri, and many
millions in the US. Their numbers are increasing; in an article in the Washington Post about the “Governments
may push workers out of employer health care and into health exchange”,
cited by Don McCanne’s “Quote
of the Day” for April 26, “The owner
of Olive Garden and Red Lobster restaurants, for example, began experimenting
last year with putting more workers on part-time status.” While the focus
of the article is on insurance exchanges, the probability is that low-wage
workers who are put on part-time status would be more likely to qualify for
Medicaid expansion.
Opponents of Medicaid expansion, in Missouri, Kansas, and
elsewhere, often sound concerns about the cost, despite the fact that the
federal government will pick up almost all of it. On the finances, they are
wrong. But of greater concern they are not really motivated by their flawed
understanding of economics, they are motivated by a lack of concern for people
who are not like them, and a commitment to policies which expand the wealth of
the richest individuals and biggest corporations at the expense of regular
people. As the “American Viewpoint” survey points out, it is not the belief of
most people, who do care about the health needs of themselves, their friends
and neighbors and relatives. And, maybe even, other people who they don’t know.
The ACA, even with Medicaid expansion, even with insurance
exchanges, even without changes to DSH or Medicare, does not cover everyone.
Glaringly missing are those who, although without papers, are here, working in
our community, living by our sides, often paying in through taxes (sales for
sure, and frequently income) and sometimes needing health care, as well as
others who fall outside the complexities of health insurance coverage. What we
really need is an expanded Medicare-for-all, “everyone in, nobody out”. This is
the real rational plan. But ACA does cover children up to the age of 26, it
will prevent insurance companies from denying coverage to those with
pre-existing conditions, and if states proceed with Medicaid expansion, will
cover a whole lot more people who desperately need it.
People like Paul Nelson. People like the folks across the
street. Maybe people like you. Our people.
2 comments:
Thanks Josh, I am drowning in conservative, less than studied responses to all of the ACA plans. It is so refreshing to get your blogs. I read them all. Eldonna
Thanks josh, Your blog helpful for me. It is so refreshing to get your blogs. I read them all.
Medical Affairs Mismanagement
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