The most successful part of the Affordable Care Act is built on a simple idea: Expand Medicaid. This is government-sponsored health insurance that works. Medicaid covers more children and more adults whose jobs pay too little for them to buy the market-based plans. The result is an insurance umbrella that added nearly 12 million people to the ranks of “covered,” and Medicaid now covers 1 out of every 5 Americans.
The idea was even better in the original ACA legislation: It was a nationwide mandate to do more, expanding coverage in every state. But in June 2012 the Supreme Court ruled that states could not be compelled to expand Medicaid. The result was a confusing mix of 31 states (plus the District of Columbia) that expanded Medicaid and 19 states that did not.
The House Republican-proposed replacement for the ACA basically swaps government regulation for private regulation by insurance companies. Instead of the federal government mandating insurance, companies would be able to charge a penalty for anyone whose insurance policy has lapsed. Speaker Paul Ryan still uses this shift to explain why the ranks of the uninsured will rise. He says more people will choose to go without.
Forget the mandate. Or even the individual plans. The most important element is the radical upheaval of Medicaid. That’s that the plan that insures people who really want (and need) to see their doctors.
The thing is that Medicaid (insurance for low-income Americans) and Medicare (insurance mostly for older Americans) are the closest programs this country has to single-payer insurance. And both programs work. Quite well, actually. Medicaid and Medicare deliver health insurance at a lower cost. Medicaid costs per beneficiary grew slower than private insurance, according to the Center for Budget and Policy Priorities.
Republicans argue that many doctors refuse Medicaid patients. While that can be a problem, data show strong evidence that Medicaid does lead to better access to doctors and to better health outcomes.
A study in Oregon found that adults with Medicaid coverage were 25 percent more likely to report they were in good-to-excellent health (versus fair-to-poor health), 40 percent less likely to report health declines in the last six months, and 10 percent more likely to screen negative for depression. Real success stories.
Perhaps just as important, the study found that Medicaid significantly reduced the financial hardship of participants. This one government program made the poor less so.
“Respondents reported that Medicaid virtually eliminated out-of-pocket catastrophic medical expenditures and reduced the probability of having to borrow money or skip paying other bills because of medical expenses by more than 50 percent,” reported the National Bureau of Economic Research. It also found that credit reports showed that “Medicaid decreased the probability of having an unpaid medical bill sent to a collection agency by 25 percent.”
This country has been stuck on a narrative that government does not work. Or that antipoverty programs don’t make people’s lives better. Not so.
I could write another 10,000 words on why Medicaid is not perfect, but it’s better than good and far better than no insurance at all. We should be building on that success, not taking it apart.
We should be building on that success, not taking it apart.
That’s why Monday’s Congressional Budget Office scoring of the House Republican plan is so important. It predicts that the number of people who are uninsured would increase by 18 million in the first year following the bill’s enactment. And, after Medicaid is turned into a block grant program, that number would grow to 27 million in 2020 and to 32 million in 2026.
These are unconscionable numbers. Then again, House Republicans are probably cheering the CBO score that says dramatically cutting Medicaid “would reduce federal deficits by $337 billion over the 2017-2026 period. That total consists of $323 billion in on-budget savings and $13 billion in off-budget savings.” That’s a lot of money.
But my guess is that neither Congress nor American citizens are ready to sacrifice that many people in the name of budget savings. Medicaid and its twin Medicare are popular and successful because they are easy to use and make us healthier—and because those reliable insurance programs already cover 36 percent of Americans.
We need more, not less.
Mark Trahant is editor-at-large for Indian Country Today. Trahant leads the Indigenous Economics Project, a comprehensive look at Indigenous economics, including market-based initiatives. Trahant is a member of the Shoshone-Bannock Tribes and has written about American Indian and Alaska Native issues for more than three decades. He is a member of the American Academy of Arts and Sciences and has held endowed chairs at the University of North Dakota and University of Alaska Anchorage, and has worked as a journalist since 1976. Trahant is a YES! contributing editor.