There were three very interesting nuggets of news in the past couple of months that highlight the continual entrenchment of the ACA into baseline expectations of the national political system. The biggest one is the least likely to immediately occur:
Texas GOP Rep Seeks To Create State-Based Exchange https://t.co/jflnrbRUpN
— InsideHealthPolicy (@InHealthPolicy) March 7, 2023
Texas is thinking about launching a state based marketplace. The concept of operations is that Texas can run their own Lone Star Health website cheaper/better than Healthcare.gov. The wedge of money that otherwise would have been spent on Healthcare.gov could be used for other, local priorities. This was basically the motivation for Pennsylvania to move to a state based marketplace. Running Pennie cheaper than Healthcare.gov basically funds a reinsurance waiver for Pennsylvania. The second big argument for a state based marketplace is that it gives a state way more flexibility for other waiver programs.
In 2010-2011, the Obama administration expected to see most of the individual market to be insured through state based marketplaces. The federal government had a fire hose of grants to help states set up state based marketplaces with the expectations that governors would want local autonomy and a local credit for helping their residents get insurance. The expectation was even in red states, lots of people would get insurance and like their insurance from the state based exchange with state relevant branding while hating Obamacare — this is what we saw in Kentucky.
However as part of deep, broad and pervasive conservative resistance to the ACA, conservative advocates argued that red states should do nothing to support the ACA and rely on Healthcare.gov so they could rally against out of touch Washington bureaucrats. Idaho was the only Republican trifecta state that ran its own marketplace on the thought that the “ACA is here, we’re not thrilled with it, but we can locally control it…”
But that dam seems to be breaking. Georgia has filed to stand-up their own state based marketplace for the Fall of 2023. Texas is thinking about a state based marketplace. It seems like acceptance and modification of the ACA is occurring.
Finally, North Carolina looks like it will expand Medicaid. It will expand Medicaid by regular order in a Republican dominated legislature with a bill that is likely to be signed by a Democratic governor. This is important as the last gasp of Repeal and Replace in 2017 was known as the 26 governor strategy— craft a bill that sends a lot of money to 26 governors and get money from mostly Blue states with low uninsurance rates — primarily Massachusetts, New York, and California —. The big component of the opposition to repeal and replace that was likely decisive was the bipartisan governor coalition where the common thread was that the states had expanded Medicaid.
So if we’re thinking about entrechment and embedding, this has been a very good quarter for the ACA.
OzarkHillbilly
Very good news indeed.
Dorothy A. Winsor
I tried to get a second bivalent COVID booster yesterday, and the pharmacist wouldn’t do it. It’s been six months since my previous bivalent shot, and we’re traveling at the end of this month. I thought maybe a second bivalent show might be allowed because I’m old.
Anonymous At Work
What’s causing the dam to break, especially in Texas? North Carolina, Republicans are preemptively removing a potent political weapon for Democrats. Georgia, I figure, might be the same.
I figure Texas is about money, since it’s always about money in Texas. Does Texas have a chance at running a decent state marketplace in a state dedicated to never taxing and never spending money?
Jerry
That’s easy enough for Josh Stein to get around. Just use that as an example of Democratic ideas that work and he’s got a ton more that will also work for the wonderful people of the great state of North Carolina.
Burnspbesq
A rare outbreak of common sense in Texas. It might even get through, since the crackpots in the Legislature are so focused on bullshit culture-war issues and destroying the public schools that they might not notice a tiny bit of soshulism.
Matt McIrvin
@Dorothy A. Winsor: I just saw a PSA from the government saying that if you last got a booster in September, your protection is waning, and you should get the bivalent booster. But the one they were giving in September was already the bivalent booster, so that made me think that maybe they’d changed their recommendations and were allowing/recommending additional bivalent shots. I think things are very unclear right now. I can’t even really tell whether they’ve authorized them or not by looking at the CDC’s website–the information seems to only make sense in the context of several months ago. They say you should get ONE bivalent shot if your last shot was more than a few months ago, but of course if that one was already the bivalent shot, I’m not sure even they know what that means.
Matt McIrvin
@Anonymous At Work: I think the ACA has lower political salience than it used to, the anti-Obamacare rhetoric cooled down a little, so Republicans can creep toward implementing it without worrying that they’re committing ideological treason. They’ve moved on to other things.
Parfigliano
I imagine it will work as well for Texas as Texas having its own electrical grid does.
Matt McIrvin
…This kind of thing is how liberals can actually win policy over the long term even though it feels like we lose almost every big fight.
Dorothy A. Winsor
@Matt McIrvin: Yeah. The pharmacist said she expected some CDC action this week, but of course, she kept calling it the “biovalent” shot so I wasn’t filled with confidence.
Matt McIrvin
@Dorothy A. Winsor: If I had to guess, I’d say they’re going to recommend a yearly shot for most people and a six-month shot for over-50s and high-risk people. But I’m no public-health expert.
Delk
@Dorothy A. Winsor: I was at my pcp yesterday and he said to hold off. I have an appointment with my infectious disease doctor in a couple of weeks and plan to ask his opinion.
btw, the bookstore down the street from me has a YA book club for adults that may be of interest to you.
Manyakitty
@Matt McIrvin: I saw my GP yesterday and she said for those of us with 5 total shots, she’s expecting a recommendation for annual boosters in the fall, along with the flu shot.
Fake Irishman
@Anonymous At Work:
The dam has steadily been eroding over the last decade. Every year, another state or two adopts the Medicaid expansion. Every year, a few states file for a new ACA waiver — and most of them (eg reinsurance) are fairly mundane.
It took 17 years for all the states to adopt the original Medicaid, we’re not that far off on this one.
Dorothy A. Winsor
@Delk: That club looks excellent! Thank you.
It’s true that many YA books are sold to adults for their own reading. The books are pacey. They move along. And they tend to have the emotion right there on the surface, which can pull a reader in.
Fake Irishman
@Burnspbesq:
they did expand Medicaid to a small group of postpartum moms in the last session, which was a big win in a session dedicated to voter suppression, so this would be on brand.
Also, the civil servants in Texas are actually pretty good at what they do mostly. (It’s just they don’t have scope to do a lot or the funding to do it). There’s been a group in the department of health who have been gaming out a Texas exchange since 2011 and working hard in implementing Obamacare.
There’s a book called “Obamacare wars” written by a couple of political scientists that breaks down the details of what got implemented and what didn’t on a state by state level. Definitely academic prose, but a very enlightening read.
David Anderson
@Matt McIrvin: Precisely this — and tinkering with the Exchanges is way cheaper (ideologically and financially) for a red state legislature than expanding Medicaid.
Delk
@Dorothy A. Winsor: it’s a nice local bookstore just off the brown line. They have story time for kids (some with drag queens! The horror! ) at the plaza across the street. They host authors for signings and readings so you may want to contact them for your upcoming book.
Matt McIrvin
@Fake Irishman: I could still see some federal troll lawsuit in a cherry-picked jurisdiction succeeding in destroying the ACA over a punctuation mistake or something, because it’s something that a small number of fanatics can do by themselves without wider political support.
But as the political heat on it goes down, I guess that becomes less likely.
Anonymous At Work
@David Anderson: So, it’s like the HPV Vaccine uptake? Vox did an article on the topic but neglected that the “Giving the HPV Vaccine will turn my angelic daughter into a liberal slut!!!” crowd has accepted their doctors’ recommendations once the culture wars moved on to new ground.
Matt McIrvin
@Anonymous At Work: That’s encouraging–it suggests that COVID-induced antivaxxerism could gradually fade once the right has stopped focusing on it and it becomes obvious to even the unobservant that there is no pandemic of people dropping dead from the vaccine.
There is no Peak Wingnut but their focus on any particular given issue can fade.
Matt McIrvin
@Manyakitty:
Based on the stats on long COVID, that kind of frustrates me–I’d have wanted more and I suspect this is a politically motivated compromise to some degree.
It’s interesting, wastewater counts are way down in my area but it seems there’s been a recent rash of my coworkers and their families getting COVID (starting with me). We aren’t even meeting in person most of the time so it’s not a simple COVID cluster. I think it’s a group selected for willingness to have gotten the bivalent booster last fall, which maybe kept us from getting hit by this wave earlier.
CaseyL
@Dorothy A. Winsor:
I was all signed up to get a 2nd bivalent shot, and it wasn’t until I checked in that they told me I couldn’t get one until the CDC said so. It has been 6 months since I got the first bivalent booster, but I thought the OK for age 60+/with co-morbidities to get a second one was already in force.
Ah, well. I would like to get a 2nd bivalent before going overseas this summer
ETA: And, per @Manyakitty:, it looks like that won’t be a-happenin’, if the rule’s going to be “annual, in Autumn, with the flu shot.”
Dorothy A. Winsor
@CaseyL: That’s exactly what happened to me. I was all signed up, but nope. Not happening.
Eunicecycle
@Dorothy A. Winsor: we went to get our first Shingrex shot last week and the guy ahead of us was trying to get a second bivalent. Same answer to him.
Manyakitty
@Matt McIrvin: she’s also frustrated by the lack of guidance, but I guess this is where it stands for now. To my knowledge, I’ve still managed to avoid the plague and want to keep it that way. Waiting until fall for my next booster makes me nervous.
Manyakitty
@Eunicecycle: make sure to set aside some time to rest after the second Shingrix shot. Knocked me out for well over a week. Still better than getting shingles.
Mike E
NC finally expanding Medicaid (implementation TBD) is a net positive for all the uninsured but the TEA legislature will make sure to claw back other program funds in the budget, and then force Gov Cooper to sign the compromise into law. Devil’s in the details, sadly.
Fake Irishman
@Matt McIrvin:
they have tried that twice now and failed…
There are a few more troublesome lawsuits out there that could undo some of the core mandates of the ACA (Dave discussed one yesterday) but as he also pointed out there are administrative ways to get around them.
And remember when the Trump administration tried to kill cost sharing subsidies and ended up giving ore than a million people free health insurance?
Timurid
Supposedly one reason for the stubbornly high Covid death rate is under-boosting, especially in older people…. so now they want to make sure everyone is under-boosted? The only reason we can get away with one flu shot a year is that flu season lasts less than half the year. Covid season lasts 12 months.