Wednesday, September 23, 2020

At The American Prospect: Medicaid, the ACA's mainstay

As in 2018, political warfare over healthcare -- now escalating in the wake of Ruth Bader Ginsburg's death -- is focused on "protection for people with pre-existing conditions." While the war of words focuses on rules governing the individual market for health insurance, which insures about 3% of the population, the real fight is over the extent to which the federal government will subsidize health insurance for those who lack access to employer-sponsored insures. The pre-existing condition that matters most is low income.

The main engine by which the ACA has reduced the uninsured population is Medicaid. Obscuring this fact distorts our political debate as well as federal and state government response to the pandemic.  I made that case in 2018 in USA Today, and today I've made it again in The American Prospect:

In the 35 states (including Washington, D.C.) that have so far enacted the Medicaid expansion (rendered optional to states by the Supreme Court in 2012), Medicaid enrollees who fit the ACA’s expansion enrollment criteria outnumber marketplace enrollees by a 3-to-1 margin—15.3 million versus 5.2 million as of February 2020. Yet the marketplace still sucks up all the oxygen in the public perception of the ACA.
I hope you'll read the whole thing. The argument concerns first the terms of political debate, and second the focus of government efforts to insure those who lose job-based coverage in the pandemic.

The piece is a bit of a polemic. Two points about the marketplace I've made elsewhere, but cut for space: 1) poor takeup among those eligible for subsidies is due as much to ignorance of what's on offer as to informed decisions that the subsidized offerings are unaffordable, and 2) while the marketplace serves a small percentage of the population at any given time, its protections for people with pre-existing conditions matter to the under-65 population at large, in that anyone can lose access to employer-sponsored insurance at any time. (The ACA has also, secondarily, boosted protections and coverage in employer-sponsored plans.) Still, many more people who lose access to employer-sponsored insurance will end up in Medicaid than in the marketplace. 


  1. Thanks for the article. You should also focus on funding for Medicaid. Even liberal states resent the way that Medicaid seems to gobble up their budgets.
    The cost of Medicaid nursing homes can take money away from education, for example.

    This problem may get worse in the short run, as state tax revenues will be down during the pandemic.

    The long term solution is to federalize the program, but in the short run we need some kind of federal revenue sharing.

    Incidentally, there is an article on Christian health insurance plans in the Prospect right after yours, it is a powerful piece.

  2. Thanks for this article! I tried to give you a shout out on Twitter, but I think I tagged the wrong A Sprung!
    But I believe nothing will happen in the US until a working majority of Americans agree on the basic morality of universal healthcare. See here: