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.
princess leia
“The Senate’s top five Republican leaders have cosponsored legislation to extend until 2017 the Obamacare insurance subsidies that may be struck down by the Supreme Court this summer.” from TPM
RaflW
Well, we all have heard eleventy billion times that O’care is a failure because it didn’t sweep in single-payer in all 50 states. There are unicorn-chasers in every crowd. Mother Jones is certainly no exception.
Put another way, “perfection being the enemy of the good” is not just a phrase in want of a problem.
Trentrunner
@princess leia: Among other things, that signals to SCOTUS that they can abolish the subsidies, because now the Senate will “fix it.”
God help us all.
Samuel Knight
I’d argue that it actually another counterfactual that has to start now. So far the Administration has had to deal with desperately trying to make progress with a law that was fairly unpopular.
But now as the law’s popularity rises and it becomes clearer how it works, the political dynamic changes and the administration needs to play hardball. If there is no Medicaid expansion this drives a wedge between the Tea Party yahoos and the business, particularly the hospital interests in each state. Force that fight, in most cases the yahoos will be told to shut up.
And that will bring fuller coverage to the people who get it, and make the system as a whole less kludgy.
Time to move to offense, no more concessions.
SP
But Bully Pulpit! Leading with Leadership! All he has to do is use his Green Lantern!
Frank Wilhoit
So how high could they count with their shoes off? 22? 23?
NCSteve
I love MoJo, but, hey, face it, on any given day, stories arguing from the wrong counterfactual constitute about 40 to 60% of the stuff on the front page there–along with 95% of all emoprog butthurt comments on them. The “Obama is Doing This Terrible Thing!” narrative frame based on implicit counterfactuals where he either lives in a Platonic ideal universe or else has one majorly kickass Green Lantern ring is the mainstay of leftwing clickbait.
Fortunately, there are no front pagers here who link to that kind of thing on a regular basis.
Davis X. Machina
Good Radicals understand this, used to understand this..
“Do you inquire why, holding these views and possessing some will of my own, I accept so imperfect a proposition? I answer, because I live among men and not among angels…” Thaddeus Stevens, 1866.
Arclite
It boggles the mind that the states that rejected Medicaid expansion are by and large the conservative bible-belt states. But if you ask, “What would Jesus do?” he would expand Medicaid to help the poor. It’s counter-intuitive that conservative Christians hate the poor so much.
WereBear
@Arclite: Southern Baptists formed their branch of Protestantism so they could hang onto their slaves.
It’s baked in.
Arclite
@WereBear: Well, I’m not sure that’s equivalent? Slave owners didn’t recognize (or let themselves recognize) black people as equal to themselves. They viewed them the same way they viewed their cows or chickens or pigs. They don’t have that excuse any more. You think it’s the same thing? Poor people are the same level as dogs?
WereBear
@Arclite: I’ve lived in Florida. Their poor white people are regarded as serfs. They can barely get by on what they are paid, working service jobs in a state with high tourism, and very very little in the way of services.
I’ve seen how they work it close up. Yes, it’s fine with them if the poor die.
boatboy_srq
@Arclite: To some people, possibly on lower levels than dogs. They don’t need an excuse, but you’ll hear “explanations” in all the “makers v. takers” speeches and all the “entitlement” arguments – and especially in all the “Islamic terrorist” jingoism.
Fake Irishman
Amen, Richard.
Emmy Lou
I live in Tennessee, where our hapless governor has been handed his ass -twice- by a Tea Party-dominated legislature that refuses to take up his expansion plan, Insure Tennessee. I urge HHS to KEEP granting waivers because it is driving huge wedges between the traditional GOPers who still hold the power positions, and their traditional constituencies.
Insure Tennessee is overwhelmingly favored by both the TN Chamber and the TN Hospital Association – the latter HAS AGREED TO FUND THE 10% COST when fed funding drops. Seriously. There’s literally no cost to the state and the Feds have promised to let us kill it at any moment. Yet still the TP digs its heels in, screaming LALALA all the way.
Sorry for the shouty caps, but it’s nuts here. HHS needs to keep the pressure up while still providing an out, should the few remaining adults in the room find a politically viable way to actually represent the interests of our people, who are suffering mightily.