The Long Battle for Medicaid
Welcome to Interviews for Resistance. Since election night 2016, the streets of the United States have rung with resistance. People all over the country have woken up with the conviction that they must do something to fight inequality in all its forms. But many are wondering what it is they can do. In this series, we’ll be talking with experienced organizers, troublemakers, and thinkers who have been doing the hard work of fighting for a long time. They’ll be sharing their insights on what works, what doesn’t, and what has changed, and what is still the same.
Sarah Christopherson: My name is Sarah Christopherson. I am the Policy Advocacy Director for the National Women’s Health Network, and [I direct federal policy initiates] for our joint initiative Raising Women’s Voices for the Health Care We Need.
Sarah Jaffe: We are talking a few days after the Republicans, once again, failed to get votes for a “repeal and replace” plan for the Affordable Care Act. Your organization was involved in fighting for the ACA and has been fighting for health care for a while. Let’s start with the ACA: despite whatever flaws it has, it did change the politics around health care in a way that Republicans have found very difficult to change back.
SC: Absolutely. I think everybody would recognize that there are things that need to be fixed, some underlying issues with the law, and some things that Republicans exacerbated and sabotaged that now need to be fixed. But what has been strangely exciting about this repeal effort is that it really has stopped people, made them think about everything they gained through the Affordable Care Act. [It] has made the Affordable Care Act incredibly popular but has also changed this conversation about how people think about health care and the role of government [in] providing health care.
One of the reasons I think Republicans have really struggled in their repeal efforts is that they are playing on our terms. Even among Republicans, you get polls showing that there is now an expectation, after the passage of the Affordable Care Act, that people have access to affordable health care, and that there is a role for government to play in providing that. So in these repeal efforts, Republicans haven’t really been able to come out and say, “Actually, we are comfortable taking insurance away from 24 million people.”[*]
They have to dodge and hide what their actual repeal proposals will do because even some of their core base voters like the coverage they gained [under the ACA]. They like the Medicaid coverage they gained. There is this expectation that it is no longer appropriate for an incredibly wealthy society to leave millions of people uninsured. It has been a game changer in terms of how we think about health care and access to health care.
SJ: Last week, they voted on three different proposals. They voted on straight repeal of the Affordable Care Act. They voted on this plan that grew out of the House bill, the Better Care Reconciliation Act. Then, they voted on “skinny repeal.” One of the things that was noted about the skinny repeal was that it left the Medicaid expansion in place and repealed the individual mandate, which is one of the inherently conservative proposals that came out of the Heritage Foundation. I want to talk about the Medicaid expansion, in particular, and the fact that the market portions are actually the parts of the ACA that are less popular, and that Republicans thought they might be able to get rid of [them].
SC: Absolutely. There is a lot to talk about here, but even among Trump voters, when you look at polling among Trump voters, they are really happy with their Medicaid coverage. Medicaid is good coverage, and it polls really well. When you look at some of the Trump voters who had private health insurance plans in the individual market, they were exposed to a lot of that free market risk, higher deductibles, and they were really envious of the folks on Medicaid. They looked to Trump and his promises that he wouldn’t cut Medicaid, that he would give great coverage to everybody. They looked at what folks on Medicaid had, and that is what they wanted. Far from [wanting] to repeal Medicaid, to get rid of the Medicaid expansion, to cap and slash funding for traditional Medicaid, they were looking at Medicaid and saying, “We want that.”
It has been really difficult, too, for Republicans because, again, they have been sort of disingenuous in how they have been couching their own bills. They have complained about things in the Affordable Care Act like, “Deductibles are too high.” I agree, deductibles are too high. Their bills would exacerbate that in all cases. [The] CBO said this would lead to more costs being put onto consumers. This would lead to more exposure to market risk.
Then, again, we come back to what Republicans have wanted to do. If they are going to stick with nice sounding phrases like “freedom” and “free market,” they can’t get away from the fact that when people think about health care, they don’t want to be exposed to market risks. They want good coverage at reasonable prices with the accountability of knowing that coverage is going to be there even after they get sick. People don’t want to have to, on their way to the ER, stop and say, “Wait, is this in my health plan?”
Then, of course, you mentioned the so-called skinny repeal bill. They immediately tried to re-brand that as the “Freedom Bill.” I think that it is the freedom to lose your insurance, have-your-insurance-taken-away-from-you bill. But they wanted to get rid of the individual mandate, which, as you mentioned, was originally a conservative idea. That is how you create market participation in a private insurance market, but you still have the consumer protections; you need that individual mandate. They were perfectly willing to get rid of the individual mandate and then let the private insurance market blow up.
I think that would push more and more people towards a single payer model or a public insurance model of some kind. Their efforts could really, really backfire on them. They have already backfired on them in terms of making the Affordable Care Act more popular and making single payer more popular.
The repeal effort isn’t dead. It is sort of undead procedurally. What they voted down last week, these three amendments, they could still, theoretically, bring back that underlying bill, ram it through with fifty votes and the vice president. But, they could really, if they somehow manage to do that, end up sabotaging themselves.
SJ: It is this interesting thing, too, because to keep it at a fifty-vote threshold rather than a sixty-vote threshold—because presumably Democrats would filibuster any attempt to undo parts of it or the whole thing—they have to do it through budget reconciliation.
SC: The Affordable Care Act was passed with sixty votes. That 906 page bill that we think of as the Affordable Care Act was passed regular order, a month on the Senate floor, twenty-five consecutive straight days, passed by sixty votes. It was actually this much tinier fifty-five page package of fixes that was passed through reconciliation. Part of the reason why Republicans are struggling is that their talking points for years have been, “[The] ACA was rammed through on budget reconciliation.” It is not true and because it wasn’t passed through reconciliation, it was passed through regular order, they can’t really do everything they want to do through reconciliation. So their own talking points have caught up with them.
SJ: On Twitter, people love digging up old tweets from politicians that describe what they are doing now. That game has been really interesting around health care because Mitch McConnell’s whole thing was, “This was undemocratic,” and, “How dare you?” The one that I am really surprised didn’t get revived, actually, was death panels, considering this bill would literally have been a death panel.
SC: Right. I think advocates for health care tried to point out that taking health insurance away from people will result in hundreds of thousands of people dying prematurely.
People don’t want to have to, on their way to the ER, stop and say, “Wait, is this in my health plan?”
You had Republicans—I am from Utah, I think even my own senator, Orrin Hatch, had said something along the lines of “Oh, that is so inappropriate. You can’t say those kinds of things.” It is literally true that if you take health insurance away from people and they can’t access health care some of them die. It is not an untested hypothesis here. But, yes, it is surprising that death panels didn’t get more traction this time around.
SJ: Going forward, there are still problems with the ACA, and Trump is threatening to sabotage it from the inside. Tell us a little bit about where things will stand if the Republicans cannot pass any sort of bill.
SC: Insurance companies need to set their rates pretty soon for the next year. If Trump is threatening to not fund the part of the bill that, frankly, he is legally obligated to fund—under the law, insurance companies are required to offer this support in paying deductibles to low income people. Then, the feds are responsible for reimbursing them. If Trump fails to do that, not only could we see big premium spikes, we could see insurance companies taking the federal government to court, getting that money several years later, after people paid out these incredibly high premiums, after some insurance companies have dropped out of the market.
And not only is he threatening to sabotage the ACA, he has already taken a lot of steps. He has hinted that he might not enforce the individual mandate. He cut off funding for advertising open enrollment. He shortened the open enrollment period that people could get coverage. People might find in the middle of December that suddenly that is too late for them to sign up. He is already taking all of these steps. He is so incredibly crass in how he describes it that “I am going to hurt people, but I am not going to own it. They are going to blame the other party.” Never mind that no American president should want to hurt his own constituents, his own people, for political gain.
Putting all of that aside for a minute, it is really an open question how Congress responds to this. He has also threatened to go after Congress’s own health care premium support. So, how Congress responds—in the ACA debate we have seen people like Lisa Murkowski really bravely stand up that kind of bullying and pushback. Then, we see people like Dean Heller, who seems to have crumbled in response to Trump’s bullying. That picture of him sitting next to Trump laughing makes me cringe at the craven crumbling aspect of it.
So, how Congress responds is an open question, but there are definitely some members of Congress who don’t want to see the exchanges fail, [either] because they really care about people or because they don’t want to take the political blame. There could be some movement towards taking some common sense steps, among them, funding these subsidies to help low income people get lower deductibles. Then, there have been some sweeteners in these bad Republican repeal bills that Democrats and advocates for health could certainly get on board with, like state stabilization funds that help smooth out some of these premium costs. There are some other really exciting proposals, including letting people buy into Medicaid. So, if there is a county that doesn’t have a private insurance option, letting people use their ACA subsidies to buy into Medicaid. That could be a really exciting option.
They tried three different repeal efforts in the Senate and none of those three could get to fifty. So now, finally, the more centrist Republicans can stand up and say, “Look, guys. We tried it your way. We tried the partisan-only approach. Now, we have to work in a bipartisan fashion to do things to stabilize markets.” We almost had to go through this whole process of proving that Republicans couldn’t do a partisan repeal to get them to come to the table and work in a bipartisan way. I might be too optimistic here, but that is my hope.
SJ: You mentioned the sweeteners. I did want to talk about one of the particular things that a couple of these people were pushing for—funds to deal with the opioid crisis. I saw something this morning that Trump’s commission to deal with the opioid crisis says that the best solution is to—wait for it—expand Medicaid. I wanted to talk about that a little bit, the way the thing that people were trying to do to buy off these Republicans is the exact opposite of what their states really need.
SC: Yes, absolutely. It is also the exact opposite of what folks who work in substance use disorders would tell you. There is this great quote from the Republican Governor of Ohio, John Kasich, who’s expanded Medicaid. He said, [the proposed spending is] “like spitting in the ocean.” The community that really focuses on substance use disorders would say, okay, it is fine that you are going to funnel $45 billion over ten years, which sounds like a lot of money but really isn’t when you think about the scope of the problem, the ten-year window, when you are going to fold that into either twelve step programs or other care programs targeted towards substance abuse, and then you are going to take away Medicaid coverage and ACA coverage, which is how folks treat their whole underlying conditions.
You might have a substance use disorder because you have an untreated chronic dental problem and you are self-medicating, or an untreated chronic mental health condition and you are self-medicating. Depression. All of these things, that if you had access to Medicaid, if you are lucky enough to be in a state that expand Medicaid, you could get full treatment for. But if you are just getting treatment for your substance use disorder, it is this revolving door because you haven’t solved the underlying problem.
I think the community there that really focuses on this issue did a great job of saying, “This is fine if you want to give us money, but $45 billion in opioid funding is never going to make up for $800 billion in cuts to Medicaid.” And that is just the first ten years. The cuts to Medicaid the senate was proposing in the next ten years was something like $2 trillion. It was just insane.
When I say “sweeteners” I am thinking more things like state stabilization funds, reinsurance programs, but some of these other things that they threw in at the House were absurd. They were going to cut $800 billion out of Medicaid and then were going to come back and put in $8 billion in stabilization funds. $8 billion over ten years? It was ridiculous, proportionally, what they were proposing.[**]
SJ: And of course, the refusal to expand Medicaid in so many of these states was sort of the original sabotage of the Affordable Care Act.
SC: Absolutely. It is so funny because, on the one hand, this Supreme Court decision in 2012 had made it optional for states. The ACA is built around the structure that everybody would expand Medicaid and there would be no coverage gap for folks between 0% and 100% of poverty line.[***] The Supreme Court decision throws that all up in the air.
Then, you have got some states that are expanding it. The interesting thing about that dynamic is that you then have Republican governors who put a lot of political capital on the line to expand Medicaid in their states. Ohio, I mentioned. Arizona. There are a handful of others that now—because they have personally invested political capital in making this sometimes controversial decision to expand Medicaid—are potentially much more invested in it than if it had just been required.
But, the flip side is, in those states that don’t have access to Medicaid, they have much less invested in saving the ACA. The original sabotage was nineteen states. When you look at those states, ten of them are in the Deep South. You really can see this history of institutional racism when you look at those decisions to expand or not expand Medicaid.
One thing, we really prioritize women’s health, women of color in particular. So when you look at what the ACA did, it dramatically lowered the uninsurance rates for women of color, which is fantastic. But, because those states, particularly the deep south states, refused to expand Medicaid, it widened the gap.
No American president should want to hurt his own constituents, his own people, for political gain.
So, the total number of women of color who were uninsured went down, but for the people who remain uninsured a higher percentage of that is women of color because of these geographic decisions states made. As a health policy expert, it was so clear to me that what was driving these decisions not to expand Medicaid wasn’t good fiscal policy, it wasn’t good health outcomes. The data is really clear that states should be expanding Medicaid. There are obviously other issues going on regarding these decisions.
SJ: Talk about the movement that came together to stop all of these Republican efforts for repeal, and what groundwork has been laid for moving forward toward a more universal system. Because a lot of the people who got involved in this and really worked hard to fight are people whose ultimate goal is single payer health care.
SC: I mentioned in my introduction that I work with this joint initiative Raising Women’s Voices. It is a joint initiative of three organizations: the National Women’s Health Network, MergerWatch Project at Community Catalyst, and Black Women’s Health Imperative. We have, we call them regional coordinators, but they are state and local organizations around the country. We help them by giving them access to all the information that we get in D.C., distilling the policy-wonky details into something that is digestible for communities to really grab hold of. We try and share their voices back to D.C. so that women’s voices are being heard in the movement up here, women of color’s voices are being heard, LGBTQ voices are being heard up here.
But, it has been so exciting to work with organizations like Consumers for Affordable Health Care in Maine, the Wisconsin Alliance for Women’s Health, SisterReach in Tennessee, Trans-Queer Pueblo in Arizona. These organizations that have been doing really incredibly grassroots work to not only save the ACA, to save Medicaid but also to build this movement around improving health care.
That has been really exciting. I come out of more of a cut and dry policy world; I didn’t come out of a movement-building world. It has been really exciting for me to see all of the people in the great local organizations—I could rattle them all off—who are doing this great work. Then, all of the people that are either coming out of the woodwork or that these organizations are activating to really engage around this issue. I like to think that Republicans have kind of wakened a sleeping giant. That there was this level of passion that, as long as people thought the Affordable Care Act was safe and as long as they didn’t have to worry too much about it, we could let lie. Republicans have really poked that bear.
SJ: The other thing we are going to be looking for is the budget and what they are going to try to do to Medicaid through the budget. What should people be looking out for in the next few months going forward?
SC: I would say, procedurally speaking, it is really tricky. They definitely want to pass another budget resolution because they would like to get to tax cuts. One of the reasons they were so desperate to pass some kind of ACA repeal is they really wanted to lock in those tax cuts for the wealthy through health care. Then, they could go back and cut even deeper when they took up “tax reform.” The beauty of their “health care” bill is that they could cut taxes for the wealthy, pay for those cuts with health care cuts for poor and middle class families, lock in those cuts, then come back and cut even deeper.
I think it is an open question how they go from here, but they have definitely laid their cards on the table. They want to see deep, deep cuts to health care for low and middle class people, Medicaid or Affordable Care Act, but regardless, deep cuts to these programs to pay for tax cuts for the wealthy. That is not going to go away.
Even if we could formally somehow move away from ACA repeal, we can’t let our guard down because we know what they want to do. They are going to keep coming back for Medicaid. They are going to keep coming back for any way where they can really have this incredible transfer of wealth away from low and middle class people to the wealthy. I don’t think that is going to stop. We are going to fight that battle until people who support affordable care regain the levers of government.
SJ: How can people keep up with you and with your work?
SC: You can check us out at www.NWHN.org. You can follow us on Twitter @TheNWHN. You can follow Raising Women’s Voices at www.RaisingWomensVoices.net, and you can follow us on Twitter @RWV4Healthcare. We have got a pretty active social media presence. We have really had a great team in terms of coming up with social media shareable graphics that distill these really wonky terms down into something that is easy to share, easy to get.
Interviews for Resistance is a project of Sarah Jaffe, with assistance from Laura Feuillebois and support from the Nation Institute. It is also available as a podcast on iTunes. Not to be reprinted without permission.
[*] A Congressional Budget Office analysis of the American Health Care Act of 2017 estimated that 23 million more individuals would be without health insurance by 2026 than would be the case under the Affordable Care Act. A July report from CBO estimates 32 million individuals would be without health insurance by 2026 under the Senate’s plan to repeal the ACA without providing a replacement.
[**] The American Health Care Act (AHCA) proposed establishing a Patient and State Stability Fund with more than $100 billion over the course of ten years.
[***] The Affordable Care Act (ACA) expands Medicaid eligibility to nearly all low-income individuals with incomes at or below 138 percent of poverty