There’s still a long way to go -- and a lot of enrollment left to do -- but the worst fears of ACA advocates, and the fondest wishes of its opponents, haven’t been realized. For those who said it couldn’t be done, or actively tried to sabotage it, this is disappointing. For everyone else, especially the millions of people who finally have access to health care, it’s great news.
However, the numbers of people covered under ACA could -- should -- be much higher. Why aren’t they? Blame Rick Perry.
The Texas governor is one of the many, many state-level Republicans who are keeping ACA’s coverage numbers down by interfering with the law, most notably through refusal to accept the ACA’s expansion of Medicaid for low-income families.
The Supreme Court’s decision in 2012 opened the door for state-level refusal to accept Medicaid funds, and governors and state legislators in red states grabbed on to refusal as a showy political tactic, a way to prove how hostile they were to President Obama and his signature health care legislation.
It’s a very clever way for politicians like Rick Perry to take an ideological stand, except for the literally millions of people who they’re hurting.
According to research by the Commonwealth Fund and the Kaiser Family Foundation, nearly 4 million people could be covered by the ACA’s Medicaid expansion but aren’t, because of the political theater of their leading Republican officials.
In many cases, these are states with tighter-than-average Medicaid eligibility, so the ACA’s expansion would do a lot of good. Seven of the ten highest-poverty states are refusing Medicaid expansion. Medicaid expansion is actually a pretty good deal for states, with federal funds covering most of the cost and lowered expenses related to uninsurance, but that doesn’t seem to matter.
The biggest offender is Rick Perry’s Texas, a huge state with high rates of poverty and uninsurance. More than a million Texans could be benefiting from Medicaid expansion, but apparently that’s less important than Perry’s posturing.
It’s worth noting that not every Republican politician has taken this indefensible position -- Gov. Jan Brewer of Arizona, for example, passed Medicaid expansion over the objections of many of her Republican allies in the legislature. And in normally Republican-leaning Kentucky, Democratic Gov. Steve Beshear has worked with a divided state legislature to implement ACA very successfully, putting a huge dent in the state’s uninsurance rate.
You’ll see conservative pundits and politicians attacking the ACA for failing in its mission to cover people, leaving too many people falling into the cracks. That’s adding insult to injury, because the biggest cracks are the ones deliberately created and widened by politicians like Perry.
It’s like wrecking someone’s house and then saying they broke their promise to keep their house clean. And it’s particularly grotesque when you realize this cheap stunt is happening at the expense of the working poor.
Meanwhile, Republicans in Congress are doing everything they can to make the ACA coverage numbers even lower. Every time you look, House Republicans are pushing through another attack on the ACA, with dozens of repeal votes and no end in sight.
That’s just the beginning, though. Rep. Paul Ryan released his new budget this week, and were it to become law, millions of people would lose health coverage. It includes the obligatory full repeal of the ACA, of course, which would end the insurance marketplaces and the Medicaid expansion as well as numerous other protections. But even more importantly, it would impose huge additional cuts on the existing Medicaid and Children’s Health Insurance (CHIP) programs, and offer what Medicaid and CHIP funds still existed to states in the form of block grants. That puts big decisions about health coverage for the very neediest Americans into the hands of politicians like Rick Perry, who have already amply demonstrated their priorities when it comes to health care for their most vulnerable constituents.
A CBPP analysis indicates that Ryan’s budget would cut Medicaid and CHIP by nearly a third, with enormous consequences:
Medicaid cannot readily withstand cuts of this depth without harmful results for low-income families and individuals. The program already costs significantly less per beneficiary than private insurance does, because it pays health providers much lower rates and has considerably lower administrative costs. In addition, its per-beneficiary costs have been rising more slowly than private insurance premiums for the past decade, and they are expected to grow no faster than private insurance over the next ten years...unless states increased their own Medicaid funding very substantially to make up for the Ryan plan’s deep Medicaid funding cuts, they would have to take such steps as cutting eligibility, which would lead to more uninsured low-income people; cutting covered health services, which would lead to more underinsured low-income people; and/or cutting the already-low payment rates to health care providers, which would likely cause more doctors, hospitals, and nursing homes to withdraw from Medicaid and thereby reduce beneficiaries’ access to care.
Over the coming decade, Ryan’s vision for health care would cut 14 to 20 million people out of their coverage, in addition to the millions who would lose out from his ACA repeal.
Ultimately, Republicans like Ryan and Perry don’t think government should be in the business of guaranteeing health care coverage to anyone. For the moment, with a Democratic Senate and White House, Ryan can’t make his plans a reality. But Rick Perry and politicians like him are doing a pretty good job standing between their constituents and the health coverage they could be getting.
The ACA is succeeding in many of its intended goals. But there are 4 million people being left out because of the willful actions of their state’s elected leaders. Thanks to Rick Perry, the number of people without insurance is much, much higher than it has to be.
Seth D. Michaels is a freelance writer in Washington, D.C. He's on Twitter as@sethdmichaels.