Thursday, March 30, 2017

"Medicaid expansion is the jewel of the ACA"

As Trump gleefully forecasts -- and thereby threatens to trigger -- the implosion of the ACA marketplace, methinks Democrats are starting to emotionally decouple from it. "You break it you own it" is a preemptive strike in messaging -- and potentially, a step toward planning the next phase when Democrats are in a position to shape public policy.

The AHCA's double-barreled assault on Medicaid -- repealing the ACA expansion and imposing per capita caps -- helped Democrats to see the ACA whole.  Hours before the bill hit, Andy Slavitt provided some clarity:
Now enter Harold Pollack, who has a granular sense of how Medicaid functions in U.S. society, chronicling how Republican governors' support for the ACA expansion helped sink the AHCA. Pollack, like Slavitt, reframes the ACA -- at least in public discussion forever obsessed with the private plan marketplace:
In political and human terms, Medicaid expansion is the jewel of the ACA. Within the states that embrace it, Medicaid expansion is the most important public health advance in decades.
Medicaid, Medicaid...made in the shade with a garden spade. Better yet once ACA'd...

More startling still is Pollack's conclusion:

The more ACA marketplaces falter, the more pressure will build for their replacement, which is surely an expanded Medicare or Medicaid role. If Democrats ever succeed in enacting such a public option, Republicans will quickly feel powerful incentives to join that effort, just as they felt powerful incentives to defend Medicaid expansion. 
That's very much in keeping with what UMN professor Larry Jacobs told me this week about the way progressive thought is trending:
The public-private plan was seen as a way to build broad-based support,  That's clearly not happened...What did Democrats get in terms of building long-term support for what was intended to be a more moderate approach as compared to single payer or the public option? They didn't win any Republican support for it, and it proved quite difficult to administer."

For the public option to have a major impact, I suggested, it would have to be a "strong" one -- by which I meant probably paying Medicare rates to providers.

"That's what I'm hearing," Jacobs responded. "I don't think it's formed yet, obviously people are focused on the immediate situation. But when I'm involved in conversations about what's next, it's not about going back to Hillary Clinton's agenda [mainly subsidy boosters in the ACA marketplace]. I think the last three months -- plus the last seven years -- are really leading to some new redirection and new examination."
From the opposite end of the political spectrum, Trump buddy Christopher Ruddy has urged further Medicaid expansion on Trump.  As I pointed out within days of Trump's election, that is the only way to fulfill Trump's promises to delivery affordable, low deductible health insurance to everyone.

Too bad Trump's promises aren't worth a bottle of Trump Network vitamins. But Democrats' day will come, if our political system survives Trump. And when it does, various forms of public insurance for those who currently must rely on the individual market will be in play.


  1. I could not find Pollack's actual article, so my comment may be off base:

    however, Medicaid costs per adult are now running about $6500 a year (due to some increases in fees paid to doctors, which is long overdue.)

    If we create a buy-in program, so that people pay a per cent of income for Medicaid and most do not get it for stone free, this has possibilities.

    But we must not re-create the means tested monster where Medicaid is free until you make a tiny bit of money or get some assets. The monthly churn in and out of Medicaid due to asset and income limits is monstrous, and certainly no "jewel."

    1. Oops, sorry, Bob -- I left out the link to Pollack's article, now inserted. For sure, Medicaid or Medicaid-plus extended up the income scale would be a buy-in, like MinnesotaCare, which is not particularly cheap at 200% FPL. The task force that recommended extending it to 275% FPL even had an AV 73% at the top of that income scale -- which strikes me as too low, unless the cost of care is so low that enrollee responsibility for that high percentage is affordable.

    2. In Poloack's article, the main beneficiaries of Medicaid expansion are addicts, the mentally ill, single mothers with two jobs, and younger people with horrible illnesses.

      In the feverish Republican imagination, the beneficiaries of expansion are "able-bodied" young gangsters, male and female, who interrupt their days sitting on street corners with a free visit to the doctor or ER.

      Pollack portrays Medicaid as almost Christ-like. As usual, the official conservative Christians in America mostly hate this group of beneficiaries.