Reason Slowly Gaining Ground Over Ideology in Medicaid Debate

When the Supreme Court ruled that states were not required to expand Medicaid to cover all poor adults, as originally envisioned by the ACA, it touched off a fierce political struggle that continues to roil statehouses across the country. Most recently, three Kansas lawmakers, all moderate Republicans, found themselves bumped off of a committee with jurisdiction over Medicaid because of their support for expansion.

With the 2016 election looming, political paralysis seems to rule the day (except in Montana, where more than 5,000 enrollees flocked to the newly expanded Medicaid program in its first week), but there are signs that the days of lying down in the road to prevent low-income people from getting health coverage are numbered. Consider:

In a recent poll of five swing states conducted for Community Catalyst’s On Message and SEIU, overwhelming majorities of voters in states that have yet to expand (Florida and Virginia) and states that have expanded (Ohio and Pennsylvania), including both Democrats and Republicans, supported expansion.

In deep south states such as Alabama and Louisiana, closing the coverage gap is emerging as a very real possibility.

The Kentucky Governor-elect and Tea-Party darling Matt Bevin was already forced to backpedal on his plan to repeal the expansion, and many astute observers expect that, as in Arkansas, the budgetary cost of repeal will persuade lawmakers to preserve the program.

And in Washington, Republican Senators are hesitating to cast a vote for a reconciliation bill that would repeal the enhanced federal funding for Medicaid expansion because they don’t want to come out in favor of taking health insurance away from thousands of people in their home states.

In some respects, the 2016 election looms as the final existential threat to the survival of the ACA. But the takeaway is that even if there were an ACA opponent in the White House, repeal would be harder to achieve than the political rhetoric suggests. And if a supporter of the ACA retains the presidency, there is a real chance that the ground could shift rapidly under the feet of the obstructionist caucus.

Warts and All

But if the ACA seems here to stay, that doesn’t mean everything is rosy. The issue of affordability (and the strategies insurers are using to hold down premiums) is a growing concern. According to a recent report from the Urban Institute, as financial support for purchasing health insurance tapers off, the percentage of people who are eligible for coverage but unenrolled rises.

Meanwhile, a different type of affordability problem is emerging for those with serious and chronic health conditions. The tactics insurers are using to keep premiums down and expand their market share is leading many to offer benefit packages that restrict access to necessary treatment, skinny-down provider networks and impose high out-of-pocket costs. For example, many silver-level plans restrict access to HIV medications and/or charge substantial co-payments. 

If anti-ACA fever were to break in Washington, these are problems that Congress could address (and indeed, the On Message/SEIU poll showed these are the types of issues voters want to see their elected officials tackle). What is more likely is that federal and state regulators and state lawmakers are going to have to tackle the affordability challenge without help from Congress for the foreseeable future.