Monday, June 04, 2018

ACA sabotage boomerang, type 3

Recently, I tallied the various ways that Republican sabotage of ACA programs has either backfired entirely or created means of mitigating the intended damage.

Very briefly, sabotage jacks up individual market premiums, which creates inflated federal subsidies, which can be leveraged both by individuals (via discounted bronze and gold plans) and states (via federally funded reinsurance or other innovation waiver programs). Two states, New Jersey and Vermont, have also turned effective repeal of the federal individual mandate to their advantage by creating state mandates, capturing a revenue stream while holding premiums down.

Late last week, the Washington Post's James Hohmann highlighted another form of sabotage that may also at least partially boomerang: Work requirements attached to Medicaid for "able-bodied" adults. It would be hard to find a policy more universally denounced by anyone with any professional experience or scholarly purview of Medicaid. The programs are cruel,wasteful and counterproductive; they will likely  reduce both coverage and employment. And yet...
As President Trump steps up efforts to undermine the law, from repealing the individual mandate to watering down requirements for what needs to be covered in "association health plans," the administration’s willingness to let states impose work requirements on Medicaid recipients has paradoxically given a rationale for Republicans to flip-flop on an issue where they had dug in their heels.
In states that have implemented or plan to implement them, work requirements are projected to reduce enrollment among the Medicaid expansion population by perhaps 20%. At the same time, getting the federal green light to impose such requirements provided vital political cover for Republicans in Virginia who flipped to support expansion in the wake of last year's huge Democratic gains in state government (falling just short of majorities in both houses while capturing the governorship):
A chastened House Speaker M. Kirkland Cox (R-Colonial Heights), seeking to rebrand Republicans as results-oriented pragmatists, came out in favor of expansion if work requirements, co-pays and other conservative strings were attached [internal WaPo cite to this article].
In Kentucky, work requirements offered Koch brothers' tool Gov. Matt Bevin a lighter cudgel against poor people than full-scale repeal of the Medicaid expansion, which had cut Kentucky's uninsured rate in half (and he used full repeal as a threat to get the requirements passed). Work requirements may provide a path to expansion in other red states going forward, while inducing other conservative state governments to settle for a fifth of a repeal loaf.

While it's always dangerous to underestimate Republicans' will to uninsure people, if Democrats maintain at least some electoral momentum it's reasonable to hope that while state Medicaid expansions prove permanent, work requirements will prove temporary. It's politically hard to uninsure people. When the political will is there, it shouldn't be so hard to remove onerous, expensive, nonproductive red tape.

More broadly, Democrats have a reasonable chance to preserve the funding and structure of the ACA's core programs, and so preserve three quarters or more of the coverage gains the law has effected, until they gain power again (if they ever do). That's an outcome most would have been happy to embrace in January 2017.

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