The Republican effort to repeal the Affordable Care Act is nearing its end — at least the most dramatic and consequential part. While they still might find a way to pass a bill, at the moment the most likely outcome seems that their attempt at repeal will fail, after which they’ll try to pass some kind of limited fix to shore up the exchanges. For now, I’m going to assume that will indeed be the outcome, so that I can discuss what happens next.
The biggest winner in this whole debate — and the vehicle for Democrats to take their next steps in expanding health coverage and security for Americans — is Medicaid.
This isn’t an outcome that many people expected. For a long time, Medicaid was seen as Medicare’s less glamorous cousin, insurance people didn’t fall in love with and which didn’t have a powerful constituency to protect it. “Programs for the poor are poor programs,” as the maxim has it, and Medicaid was supposedly always vulnerable to cutbacks and attacks from Republicans eager to undermine the safety net.
But when the ACA was passed, health wonks understood that while other provisions got more of the attention — the creation of the exchanges, the new protections for people with preexisting conditions — the Medicaid expansion was the most significant piece of the law in terms of the effect on people’s lives. More than 14 million Americans got coverage who didn’t have it before, and in many cases it was absolutely life-changing.
There are now nearly 75 million Americans who get Medicaid (not just low-income individuals but also those who are elderly and disabled). Republicans are positively horrified by that number. Their current health-care bill tries to do what they’ve always wanted: not just rewind the expansion, but go further to cut Medicaid back and transform the program from an entitlement (in which anyone who meets the eligibility criteria gets the benefit) to a block grant (in which people can be kicked off or denied coverage even if they’re eligible), thereby enabling it to wither over time.
Yet something unexpected has happened. This debate over health care has educated the entire country about what Medicaid does. The prospect of millions losing their coverage has helped make the Republican health-care bill the most unpopular piece of legislation in recorded history, with polls showing it supported by as little as 12 percent of the public.
And while Republicans describe getting on Medicaid as a cruel fate from which people need to be liberated, it turns out that people really like it. As an enormous survey that was released this week shows, Medicaid recipients are overwhelmingly happy with their coverage — the average score they gave it on a scale of 1 to 10 was 7.9, and 46 percent rated their coverage a 9 or a 10. And while Republicans often cite the fact that many doctors don’t accept Medicaid patients as a reason why the program supposedly stinks, only 3 percent reported problems getting care because of wait times or the inability to find a doctor who accepted Medicaid. For the other 97 percent, it apparently wasn’t a problem.
In fact, Medicaid has been overwhelmingly popular with its recipients for a long time (see here and here), but the rest of the public just wasn’t all that aware of it. Now that Republicans are threatening the program, awareness is growing, as people tell their stories and explain the devastation Medicaid cuts could cause.
The disaster of the Republican plan has opened the door for Democrats to advocate for more sweeping change to the health-care system in order to cover everyone and rein in costs. And the next wave of Democratic proposals is unlikely to center on complex, technocratic fixes to the existing system the way the ACA was. So Medicaid provides the perfect place to start — from the perspective of both good politics and wise policy.
What should Democrats propose? The first demand should be that the 19 Republican-run states that refused the Medicaid expansion finally accept it. That decision has been spectacularly stupid — the states that accepted the expansion have fewer uninsured, healthier state government balance sheets, rural hospitals that are less in danger of closing, and private insurance markets with more competitors. If your governor and/or legislature refused the expansion just to give President Barack Obama the finger, you were the one who got the shaft.
Next, Democrats should propose that a Medicaid buy-in be available on the exchanges, particularly in places where there are few private options. Republicans will object, but that’s because the idea of people being free to choose Medicaid terrifies them. If they had the courage of their convictions, they’d agree to it, because their philosophy predicts that nobody would voluntarily pick a big-government program over a private one. But they know that if the option is there, lots of people will choose it.
If and when Democrats start advocating this kind of further expansion of Medicaid, Republicans will cry that this is just the camel’s nose under the tent and will lead to single-payer health care. And you know what? They’re right. Or at the very least, it might be the first step toward creating a hybrid system with a basic government plan that covers everyone, combined with private supplemental insurance that allows you to buy as much fancy coverage as you want and can afford.
If Democrats are going to make real steps toward an outcome like that, the next time they have the power to make real change (2021, perhaps?), they should start charting their path now. They’ve been given the opportunity, courtesy of the GOP, to use Medicaid as the core of their proposals to create universal coverage and real health security. They shouldn’t waste it.