Red States Won't Expand Medicaid? Democratic Senators Have A Plan For That!
Sen. Raphael Warnock, public domain photo

For nearly a decade, Republicans in state governments have made a great show of their rightwing bona fides by absolutely refusing to expand Medicaid as part of the Affordable Care Act. They say they're fighting "socialism," and if people have to die because they don't get medical care, those people should have had the good sense to be born rich or in Massachusetts. This week, a trio of Democratic US senators — Georgia's Rev. Raphael Warnock and Jon Ossoff, and Wisconsin's Tammy Baldwin — have introduced a pretty nifty plan to get around roadblocks thrown up by red-state Republicans.

Their bill, the Medicaid Saves Lives Act, would provide Medicaid-like coverage to people in the 12 states that have still refused to expand Medicaid. (It might also apply to Missouri: Voters there passed a Medicaid expansion initiative last August, but the Republican-held legislature refused to fund it. The state Supreme Court is currently considering the case.)

First, a little history: When the Affordable Care Act was designed, it aimed to make sure virtually everyone in America had health insurance, through a combination of public and private coverage. The Medicaid program would be expanded to cover low-income Americans with annual income up to 138 percent of the federal poverty level, and the federal government would pay for 100 percent of the expanded coverage at first, with states picking up 10 percent of the costs in subsequent years. Folks making more than 138 percent of the poverty line, and who didn't have employer-provided health coverage, would buy individual private plans on the healthcare marketplace, with heavy subsidies for folks on the lower end of the income scale.

But when the Supreme Court upheld the constitutionality of the ACA in 2012, it also threw a monkey wrench into Medicaid expansion, ruling that states could choose to expand Medicaid or not. Red states, to prove they would not bow down to the tyranny of a healthy populace, mostly refused, although over time several have expanded their Medicaid programs. (In 2014, then-Governor of Arizona Jan Brewer threatened to veto any legislation her fellow Republicans sent her until they agreed to expand Medicaid. It was actually shocking, and also brave. Most red state governors did not follow her lead.) Even so, roughly four million Americans remain in the "Medicaid gap": They make too much income to qualify for regular Medicaid, but are below the income level to qualify for subsidized ACA premiums.

The Medicaid Saves Lives Act would fill in that gap by doing an end run around Republican obstructionism in states like Georgia, where, as Warnock put it last month, the GOP is "standing between ... voters and their tax dollars that are still being paid to cover Medicaid in other states."

The bill would direct the federal Centers for Medicare and Medicaid Services (CMS) to create a new healthcare program that would be virtually identical to Medicaid, to cover people in the states that haven't expanded Medicaid already. The AP has a nice summary:

The plan would require no premiums and only small copayments, while those costs can be much higher for individuals on the marketplace. People can enroll in Medicaid year-round, while marketplace enrollment is typically only in the fall, or when someone's circumstances change. [...]

Sponsors say coverage is already paid for because the original Affordable Care Act included money for all 50 states. States normally shoulder 10% of the cost, but the bill would require no state contributions.

Pretty clever, huh?

In addition to creating the Medicaid-knockoff workaround, the bill would also include additional incentives for states to go ahead and do Medicaid expansion under the ACA, by boosting the federal share of all Medicaid costs (not just the expansion) by 10 percentage points over 10 years. The American Rescue Plan included a similar but smaller increase — five percent for two years— for states expanding Medicaid, but no states took up the offer.

The senators are calling for the Medicaid Saves Lives Act to be bundled into the upcoming reconciliation bill, and that sounds like a hell of a good idea to us. (David Dayen in his The American Prospect newsletter says "the Medicaid 'coverage gap' in nonexpansion states is closed (does that mean with a public option?)" and we wonder if that means the bill is in there already, or is about to be.

Now, the AP notes there could be some complications involved in getting the equivalent of Medicaid to people this way. For one thing, it could take years to actually create a whole new program. For another,

Many states use managed care networks to provide Medicaid services, and it's unclear if the federal government would be able to contract with the groups.

And once a system that covers folks in the Medicaid gap is up and running, it might be necessary to provide incentives to states to keep them from dropping their existing Medicaid expansion, particularly since the stopgap plan in the Medicaid Saves Lives Act would be paid for 100 percent by the federal government.

Or hell, we suppose we could just go ahead and move toward real universal healthcare, with strict cost controls for services and prescriptions, like a civilized country, but this is America, where we've done things through a ridiculously expensive, inefficient patchwork of crazy systems for decades. We could deliver better healthcare for everyone, but we can't, because that would be communist.

[Fierce Healthcare / AP / Medicaid Saves Lives Act]

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Doktor Zoom

Doktor Zoom's real name is Marty Kelley, and he lives in the wilds of Boise, Idaho. He is not a medical doctor, but does have a real PhD in Rhetoric. You should definitely donate some money to this little mommyblog where he has finally found acceptance and cat pictures. He is on maternity leave until 2033. Here is his Twitter, also. His quest to avoid prolixity is not going so great.


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