Wednesday, July 18, 2012

If it is a problem, why don't you have a solution?

First published on the OccupyHealthcare blog, July 18 2012.


Just about three weeks ago, the Supreme Court ruled that the Patient Protection and Affordable Care Act (ACA) was constitutional in its requirement that all Americans have health insurance.  However, the court also decided that the ACA's expansion of Medicaid eligibility and coverage could not be forced upon the states.  States could opt to expand Medicaid as the law required, but those states that choose not to expand would not face the loss of their current Medicaid funding.  Already, a number of Governors have declared their opposition to this Medicaid expansion.

The ACA's expansion of Medicaid is an important part of the law's efforts to expand coverage and healthcare access to most Americans.  The law would require the expansion of Medicaid to cover individuals up to 133% of the Federal poverty level.  The Federal government will pay 100% of this expansion for the first three years, a level of support that gradually lowers to 90% over the next five years.  It is expected that, as designed, the ACA's Medicaid expansion would provide coverage to 17 million Americans.  The law's new health insurance exchanges, that facilitate individuals' purchase of health insurance and provides subsidies for those with incomes between 133% and 400% Federal poverty level, would account for the rest of the ACA's increase in health insurance coverage.

Late last week, the Republican Governors Association (RGA) sent the Obama Administration a letter outlining their concerns about the proposed Medicaid expansion and the ACA's health insurance exchanges.  The letter, signed by Virginia Governor Bob McDonnell, has one particularly notable passage:

The reason this passage struck me is because of its chutzpah.  The RGA's own members are those who will make the decisions for their states as to whether or not the state will expand Medicaid coverage.  However, if the state chooses not to, it is somehow the fault of the Administration for not having come up with an alternative plan.  The letter purports to show concern for those low-income Americans who would have been covered by the Medicaid expansion (if not for the Governors' decisions to reject it), and expects the federal government to provide a means of coverage for these low-income individuals.

Of course, the ACA does provide a means for low-income people to access health insurance: it expands Medicaid.  The RGA's letter is absurd, essentially saying: "If we reject the remedy you have developed to cover low-income Americans, you must come up with an alternative."  This is even more striking if one reviews the underlying reasons why the states might reject the Medicaid expansion: they claim it is a violation of states' rights.  If the states are worried about expansion of federal power, how is asking the Federal government for an answer to a state's own rate of uninsured individuals in any way logical?  If anything, the states should be fixing this problem themselves if they were following their argument to its logical conclusion.  Instead of asking for Federal help, the states should have already addressed this issue.

The states that have already rejected the ACA's Medicaid expansion include Texas and Florida.  Both states are among those with the highest rates of uninsured.

Mississippi is second on this list, and is also considering rejecting the Medicaid expansion.  The states whose residents would gain the most in terms of access to health insurance are those who are fighting this increase in access.  These three states also have Republican governors, who have not come up with a better plan to improve access to insurance as of yet.  If Republican governors truly thought that low-income Americans' access to health insurance was a problem, they have had ample time to come up with a solution...and they have not done so.

Medicaid coverage improves health outcomes, with the trade-off of an initial cost increase (possibly as those who have been insured finally access care).  With the Federal government covering 100% of the initial expansion, they (not the states) would be paying for these up-front costs.  Given that Medicaid is more cost-effective than private insurers (point 7 on this list), expanding access to health insurance via a program that is both cost-effective and beneficial is a smart move.  Meanwhile, we know that being uninsured is bad for one's health.

Thanks to the ACA, we now have the tools to expand health insurance--and health care--to 30 million more Americans.  Those who decry the law's reforms have, for the most part, failed to act in their own states and have failed to present a viable alternative.  If the ACA's opponents thought the issues of heath insurance and access to health care were a problem, they would have acted long ago.  It is time for them to stop obstructing this important step forward to improve Americans' health.

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