In an ideal world without the current assholes, sadists, sociopaths, and reactionary hacks on the Supreme Court, Medicaid expansion would have gone through in all fifty states, and there would be some interesting studies on how different states expanded their programs and coped with increased demand. That is not the world we live in. The states where there is an elite political consensus that people should be covered if possible quickly expanded Medicaid, the states where there is a joined elite political consensus that combines a moral imperative that people should be covered with a faction of people who are indifferent to that moral argument but can count to eleven with their shoes on has expanded Medicaid, and then there are the remaining twenty states that have not expanded Medicaid.
The Obama Administration has issued waivers to help build coalitions for Medicaid expansion in the states where there is no clear moral imperative elite consensus by giving policy goodies to conservatives who can count to eleven with their shoes on. Those policy concessions have ranged from allowing premiums to be charged for people who make more than 100% of federal poverty line, to expensive kludges of the states giving poor people vouchers to buy private on Exchange policies in Arkansas, to benefit reductions in Pennsylvania. In an ideal world. these are measures that weaken Medicaid’s safety net function. We don’t live in that world and for that reason, I am greatly frustrated when I read the following piece by Stephanie Mencimer in Mother Jones:
Republican-controlled states have demanded additional concessions from the Obama administration before taking part in the expansion—and in many cases, as a new paper from the National Health Law Program suggests, the administration has agreed to changes that undermine its own goal of expanding coverage….
NHLP contends that waivers like Indiana’s violate the law, which “requires demonstrations to actually demonstrate something.” As NHLP points out, reams of research have long showed that such premiums dramatically reduce health coverage for low-income people…..
That research is true, but it is a case of choosing the wrong counterfactual.
The counterfactual that NHLP is using is full Medicaid expansion without policy changes. In that counterfactual, they are right, charging premiums and having lock-out periods will decrease coverage and access to care compared to having a Medicaid expansion program that does not have premiums nor lock-out periods. However that is not the universe we live in.
We live in a universe where significant policy concessions are the difference between C+ Medicaid expansion and nothing. A+ Expansion is not in the cards for the remaining hold-out states because those politic elites are either sociopaths, nihilists or assholes, or more cynically believe that they need to play those roles to get re-elected.
In that universe, charging premiums and having lock-out periods will mean a small subset of the working poor get screwed while a large set of the working poor gets newly affordable coverage. Does it suck to agree to conditions that all the evidence says are designed to screw people over in the quest to expand coverage to a much larger population? Yes, but that is what governing actually is, making choices that sometimes suck for some people.
And when NHLP makes an argument from an unrealistic counterfactual of perfect expansion versus the compromised less than 100% actual expansion instead of what is versus nothing, they don’t help the argument of that the actual problem is the state level reactionary led governments.