Policy Analysis

One of the country’s most perilous social problems is the inequity in health care. While the country’s wealthy can afford top-notch services, many people can barely afford any services. This inequity is one of the main reason life expectancy at birth in the United States ranked 53rd internationally (The Gazetter). A Harvard University of data from 2001 to 2014 found the gap between the top 1% of earners and the bottom 1% at age 40 was 15 years for men and 10 for women. It also found the difference between the top quartile and bottom quartile was 4.5 years, and that this disparity in life expectancy could be found in myriad geographic areas and socioeconomic realms. (Chetty, Stepner & Abraham, 2016). The Affordable Care Act (ACA) was passed in 2009, enacted in 2010 and had major provisions take effect in 2014 to address this issue, but has faced several bumps along the way. A 2012 Supreme Court ruling which held up the Constitutionality of the ACA also held that states were not required to participate in Medicaid expansion. Nineteen states ultimately decided not to participate.

With Trump’s approval rating barely above 40% and Democrats having retaken control of the House of Representatives in the 2018 mid-term elections, immediate threats to the Affordable Care Act seem to be gone. But there has historically been pushback against social programs that would create more access to health care for all Americans, and some states — especially those who are led by conservatives — have tried to link Medicaid to work requirements. As a result, it should not be taken for granted that public safety nets surrounding health care will be around to help Americans who need the most assistance.

A look at the options

There were times throughout the 20th century when the idea of universal health care gained traction but never was enacted. Progressives supported Theodore Roosevelt’s plan for universal health care when he ran for President in 1912 (Igel, 2008), but the then-former President lost his campaign. Presidents Franklin Roosevelt and Harry Truman also tried their own plans in 1935 and 1949, respectively, but were stopped by opposing forces, including the American Medical Association, which argued any such program was “socialized medicine.” (Igel, 2008). With anti-Communist sentiment rising, the AMA’s pitch was successful. Perhaps not coincidentally, the next major push toward universal health didn’t come until the collapse of the Soviet Union. President Bill Clinton pushed for reform in 1993, but was met with strong opposition, and a proposed bill was never brought to the Senate floor. (Rushefsky, 1997). The ACA passed only in 2008 when Democrats held the presidency and both chambers of Congress.

There were three major portions of the ACA, according to its website, healthcare.gov: make health insurance more affordable through subsidies, expand Medicaid, and support new delivery methods of healthcare. It also featured consumer protections such as ensuring no one could be denied coverage or have their premium raised due to a pre-existing condition and allowed children to remain on their parents’ policy until age 26. Even as the ACA expanded health care access to 20 million Americans, rising premiums and deductibles made it unpopular. An Associated Press poll found only 29% of Americans supported the new law, and forces opposed to the ACA immediately began trying to dismantle it. (Brunson et al, 2018). When President Trump ran for the presidency in 2016, one of the main planks of his platform was to dismantle the ACA. It appeared the incoming President, supported by Republican majorities in both houses of Congress, would achieve that goal and pass the Better Care Reconciliation Act (BCRA). Despite the fact the Congressional Budget Office estimated 15 million Americans would have lost their health insurance by 2018 (CBO, 2017), the House passed the bill largely among party lines.

Supporters of the BCRA argued that it was a better option than the ACA because it would stabilize insurance markets, remove the law that required people to purchase health insurance, allowed them to purchase high-deductible plans, and strengthened Medicaid by allowing individual states to have more flexibility. (budget.senate.gov, 2017). The BCRA famously failed by one vote in the Senate when Sen. John McCain voted against it, casting the decisive vote in the middle of the night.

The other option is single-payer, which is basically “Medicare for All” and is championed by Sen. Bernie Sanders. The government essentially pays for all medical costs. Both the Mercatus Center (mercatus.org) and Urban Institute (urban.org) have said the plan would cost $32.6 trillion over 11 years — a calculation Sanders says is inaccurate — but both analyses say that would be a rise in government spending and might slightly decrease the overall spending on health care in the United States.

Analysis of the options

The BCRA was the latest attempt to cut funding for public health, but Medicaid funding has been under the gun for much of its half-century of existence. From Ronald Reagan in 1981 to Newt Gingrich in 1995 and under Paul Ryan today, Republicans have often proposed turning Medicaid into a block grant program. (Grogan & Park, 2017). These proposals would give states a fixed amount of money to cater to their citizens, but the amount wouldn’t increase with a higher demand. If spending is capped, tighter eligibility restrictions are enforced and people who need care are often placed on waiting lists. (Center on Policy and Budget Priorities, n.a.). None of these proposals have come to fruition, lending credence to the notion that Medicaid enjoys enough political support that rescinding benefits can be a political liability. (Zernike, et al, 2017).

However, Republicans are finding some political success with another tack: linking Medicaid to work requirements. The Obama administration had barred this, but the Trump administration allowed states to impose this requirement. One of the states, Arkansas, reported 4,353 residents were denied Medicaid by their failure to meet these requirements for three months, and another 15,000 were at risk because they had failed to meet the requirement for at least one month. (Rudowitz & Musumeci, 2018). The problem with work requirements for Medicaid is that people are often too sick to work. Brunson and colleagues (2017) describe this as possibly leading to a “downward spiral” where people become sick, can’t work, lose their jobs and the accompanying benefits that permit them to seek medical care.  In a discussion of individual cases, their work talks about a “catch-22,” where even if a worker can work part-time, that is usually not enough to allow him/her to go to the doctor.  After if a hurting patient can go to the doctor, he/she might be able to seek the medical care that would allow a medical visit. (Brunson et al, 2017).

This leads to a coverage gap, and a quantitative study has said at least 7,000 deaths and maybe as high as 17,000 annually can be attributed to states opting out of Medicaid expansion. (Brunson et al, 2017). The Kaiser Foundation found other problems with these sorts of programs, including complex implementation that could prove difficult for enrollees to navigate when it comes to the processes that verify eligibility. Also, outreach can be very problematic in impoverished areas with little or no Internet access, and the resulting coverage losses could hurt those with chronic care needs and also increase uncompensated care costs, which are often passed to the public. (Kaiser, 2018). Kaiser also maintains a list on its website of states which have sought a waiver from the federal government to link Medicaid to work requirements, and reports Indiana, New Hampshire and Wisconsin have been granted the waiver to enact such requirements, while nine more states have sought permission. Wisconsin’s newly elected governor told reporters in late November he might seek to withdraw the waiver.

As mentioned earlier, a push for universal coverage such as Sanders’ Medicare for All has always had its supporters and has sometimes been championed by presidential candidates or Presidents. Basically, it would shift the entire cost on to the federal government and away from consumers and employers, and also guarantee everyone the right to access. The problem is that opponents will seize on the $32.6 trillion figure and try to perpetuate political stereotypes about socialists wanting “something for nothing,” and how the national debt will explode. Sanders’ website counters those arguments by proposing a combination of a payroll tax that is less than what businesses pay now, an income-based tax that is less than what families pay in insurance premiums; c) an elimination of health-based tax deductions; and d) raising taxes on the wealthiest 1% of Americans.

Policy Proposal

This brief is proposing that in order to protect Medicaid, Medicare and other programs aimed at safeguarding public health, the country embrace the fundamentals of the Affordable Care Act and do its best to protect the provisions it. Although the ACA was enacted in 2010, it did not reach full enrollment until 2013, and only had three years to flourish before President Trump took office. In that time, between 20 and 24 million people who didn’t have access to health insurance were able to obtain it. (CBO, 2017). The law also has several popular provisions, including ones that prevent insurance carriers from either excluding or raising prices on those who have a pre-existing condition. It also allows children to stay on their parents’ insurance plan until age 26, and allows stepchildren to be covered, which is a big boon for blended families. Despite initial public displeasure with the program and a President determined to repeal it with help from a friendly Congress, the ACA narrowly survived a repeal attempt in 2017. Thanks to gains by the Democratic party in the 2018 midterm elections in the U.S. House, it seems very unlikely the ACA will be repealed anytime soon. However, like many social safety nets, the ACA will very likely come under attack at some point, meaning it needs to be strengthened. This would not only help ensure that it becomes woven into the fabric of 21st-century America, but it would also help strengthen the long-term health of the nation.

There are five things that can be done to protect and strengthen the ACA: a) pass legislation which will ensure cost-sharing programs will be permanent funded through mandatory appropriations (Mitts, 2017); b) pass legislation which will ensure make the temporary reinsurance program permanent, which is part of Medicare Part D and was part of the BCRA (Blumberg & Holahan, 2017); c) closing the “family glitch” so that family income will be considered instead of just an individual family member’s highest income (Mitts, 2017); d) prohibit the sale for insurance plans that are not ACA compliant, which will create more shared risk (Mitts, 2017); e) prohibit insurance carriers from selling more than one plan in a market (Blumberg & Holahan, 2017). These actions would help fix many of the complaints the ACA faces, most of which arise from a lack of funding and lack of market competition. While there’s more action that can be taken, these steps can increase affordability and increase coverage.

In these sorts of discussions, everyone not impervious to illness or injury is a stakeholder. As discussed earlier, public opinion about the ACA dipped amid rising premiums and deductables, and while some of that can be blamed on political polarization, those costs were very likely a larger factor. Legislation that would mandate the full funding of cost-sharing programs, and legislation that would affect the removal of the “family glitch,” could likely help reduce the economic stress of ACA provisions. Making a marketplace better for consumers could help sway public opinion.

Another key group of stakeholders is the medical profession. The American Medical Association, which vehemently opposed the efforts to overhaul the health-care industry in the 20th century, is supportive of the ACA. During the attempts to repeal the ACA, the AMA’s Chief Executive Office wrote in a letter to Congress, “(S)takeholders and policymakers need to work in concert to address the challenge of unsustainable trends in health care costs. The AMA is ready to work on both short and long-term solutions.” (American Medical Association, 2017). Meanwhile, the American Hospital Association is also supportive of the ACA, and has filed amicus briefs supporting Medicaid expansion (American Hospital Association, 2018).

Our Supporters and Audience

As previously mentioned, most members of the medical profession agree that strengthening of the ACA is important to the nation’s health. Their interest can be perhaps both altruistic and selfish — medical professionals are led to the field mostly by a sense of caring for others, yet they presumably do not want to provide services for free, and a continuation of the ACA will help ensure they receive compensation for their services. These groups wield a lot of political power because of their wealth and stature. The AMA spent $21.5 million on lobbying in 2017 and $15.5 on lobbying in 2018, with the 2018 figure being the seventh highest total for any entity in 2018 (opensecrets.org.). Still, the general public is the primary audience, and a plurality of Americans support it. Fifty-three percent of Americans polled in late November, 2018, support the law (kaiser.org), which is close to double its lowest mark. While the same poll found that support among Republicans has stayed under 20%, support among Democrats and political independents has risen sharply. Among independents, approval of the ACA doubled from 28% to 55% in early 2018, although it has since fallen to 47%. Among Democrats, approval is at its highest, 80%. (kaiser.org).

Given this history, we should take primary aim at shoring up support among political independents and those remaining Democrats who are not in full support of the ACA. Although not much academic research could be found on the reason independents are more often in support of the ACA, it’s possible a contributor is the fact premiums are not scheduled to rise in 2019 (cms.gov). It is also possible publicity between the two competing alternatives, the BCRA and Medicare For All, might have made the ACA look better by comparison. The BCRA, had it passed, would have allowed states to seek waivers from certain ACA protections.

Medicare For All is very popular, according to an August 2018 poll conducted by Reuters, which found 70% endorsed the idea — including a majority of Republicans. However, a Kaiser poll in 2017 found only 53% of Americans approved of the plan. Furthermore, Kaiser’s polling found that support for the idea waned depending on how the question was framed. (Hamel, Wu & Brodie, 2017). It seems very likely opponents of Medicare for All would frame the plan as more government interference in Americans’ lives. As Kaiser wrote, “The poll finds the public’s attitudes on single-payer are quite malleable, and some people could be convinced to change their position after hearing typical pro and con arguments that might come up in a national debate.” (Hamel, Wu & Brodie, 2017).

Our Presentations

The best people who can carry our message to the public are those who have had experience with the health care system — those families who have had their economic vulnerabilities exposed and as a result have gone through personal anguish, and those who have had their stories saved by Medicare or Medicaid expansion. “Anecdotes communicate the emotion and the meaning of an event. A good anecdote will have all of the characteristics of the category it represents and must be the best representation of the entire data set.” (Morse, 2006). Both forces that were pro-ACA and anti-ACA solicited individual stories to tell stories that reflected their points of view. In 2014, the White House wrote on its website, “Every single American should have the peace of mind, security, and dignity that comes with getting covered. Whether you’ve got new insurance that started on January 1, know someone who does, or simply want to help get the word out about the importance of getting covered, we want to hear from you.” (AP, 2014). One President Trump took office, the White House website was used to solicit stories from the opposite angle, writing in a blog post, “President Trump wants to hear from hard-working Americans like you. How has Obamacare affected you? Share your Obamacare disaster story.” (whitehouse.gov). The stories the Trump White House sought might have been completely difference, but the both sides chose to use anecdotes to make their case.

The other potential pool of candidates that can help us make our case are those who were skeptical of the Affordable Care Act in the beginning but have come around to viewing it favorably. As stated earlier, less than one-third of Americans viewed the ACA favorably in 2015, and now almost half of Americans view it favorably. It would be helpful to find people who have changed their minds give their reasoning, and that might be persuasive in convincing others. With the approval ratings of self-identified Democrats and Republicans steady, it would be helpful if we could find independent voters who have undergone this change of thought.

Conclusion

With our country politically polarized, many domestic and foreign issues have become largely intractable, and as such, spending on public programs will always become a hot topic. However, the fight to save and expand Medicaid, Medicare and the Affordable Care Act can continue to be a political winner if the advocacy around the issue is done with care and wisdom. There is no shortage of empirical studies showing that Medicaid expansion has saved lives and improved lives, and studies show that regardless of political ideology, people are more likely to support it if they see the connection. Advocates should continue to emphasize the humanity of Medicare, the stories and statistics behind the program, and why attempts to cut funding should not be tolerated.

References

• Blumberg, L., and Holahan, J. (2017). Strengthening the ACA for the Long Term. New England Journal of Medicine, Nov. 30 2017; 377:2105-2107. DOI: 10.1056/NEJMp1713247
• Brunson, E. K., Mulligan, J. M., Andaya, E., Melo, M. A., & Sered, S. (2018). Unrequited Engagement: Misadventures in Advocating for Medicaid Expansion. American Anthropologist, 120(3), 601–609. https://doi.org/10.1111/aman.13064
• Centers for Medicare & Medicaid Services – Effectuated Enrollment for the First Half of 2018. https://www.cms.gov/newsroom/fact-sheets/effectuated-enrollment-first-half-2018. Retrieved November 29, 2018.
• Chetty R., Stepner M., Abraham S.. The Association Between Income and Life Expectancy in the United States, 2001-2014. JAMA. 2016;315(16):1750–1766. doi:10.1001/jama.2016.4226
• Congressional Budget Office. H.R. 1628, Better Care Reconciliation Act of 2017. June 26, 2017. https://www.cbo.gov/publication/52849
• Gazetter, The – The World: Life Expectancy (2018) – Top 100+. http://www.geoba.se/population.php?pc=world&type=15. Retrieved November 27, 2018.
• Grogan, C. M., & Park, S. (Ethan). (2018). The Politics of Medicaid: Most Americans Are Connected to the Program, Support Its Expansion, and Do Not View It as Stigmatizing.  Milbank Quarterly, 95(4), 749–782. https://doi.org/10.1111/1468-0009.12298
• Hamel, L., Wu, B and Brodie, M (2017). Data Note: Modestly Strong but Malleable Support for Single-Payer Health Care. Henry J. Kaiser Foundation. https://www.kff.org/health-reform/poll-finding/data-note-modestly-strong-but-malleable-support-for-single-payer-health-care/. Retrieved November 29, 2018.
• Igel, L. (2008). The History of Health Care as a Campaign Issue. The Physicians Executive. May/June 2008. https://web.archive.org/ web/20160128114008/ http://net.acpe.org/MembersOnly/pejournal/2008/ MayJun/Igel.pdf. Retrieved November 27, 2018.
• Kaiser Family Foundation – Kaiser Health Tracking Poll: The Public’s Views on the ACA. https://www.kff.org/interactive/kaiser-health-tracking-poll-the-publics-views-on-the-aca/#?response=Favorable–Unfavorable&aRange=all. Retrieved November 29, 2018.
• Mitts, L. (2017). Building on the ACA: A Legislative Agenda to Protect and Strengthen the Marketplace. https://familiesusa.org/product/building-aca-legislative-agenda-protect-and-strengthen-marketplace. Retrieved November 29, 2018.
• OpenSecrets – Annual Lobbying by American Medical Association. Retrieved from https://www.opensecrets.org/lobby/clientsum.php?id=D000000068. Retrieved November 29, 2018.
• Rudowitz, R. and Musumeci, M. (2018). An Early Look at State Data for Medicaid Work Requirements in Arkansas. Henry J. Kaiser Family Foundation. https://www.kff.org/medicaid/issue-brief/an-early-look-at-state-data-for-medicaid-work-requirements-in-arkansas/. Retrieved October 2, 2018.
• Zernike K., Goodnough A., Belluck P. In health bill’s defeat, Medicaid comes of age. New York Times. March 27, 2017. https://www.nytimes.com/2017/03/27/health/medicaidobamacare.html. Retrieved October 2, 2018.