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My Turn: A lot to learn from success of Medicaid expansion effort

Last modified: 4/23/2014 9:42:06 AM
The passage of legislation expanding Medicaid coverage to low-income citizens in New Hampshire is a historic accomplishment. Gov. Maggie Hassan signed the bill on March 27, and the program becomes available for most people on July 1.

Medicaid expansion will cover 50,000 poor residents who previously had no health insurance coverage. Until now, Medicaid had gaps in coverage because eligibility was restricted to specific categories. If you were a single parent with dependent children, an adult with disabilities or a poor elderly person, you possibly could qualify. Now, all adults earning up to 138 percent of the federal poverty limit should be able to qualify. That translates into coverage for a single adult who is earning up to $15,856. The income limit rises based on family size.

There are many costs to being uninsured. Without insurance, people needing care often avoid it. Chronic medical problems become acute, and medical bills become a disincentive to going to the doctor. In the worst cases, medical debt leads to bankruptcy, major depression and suicidal ideation. Medical providers have needed to raise rates on insured people to deal with the large numbers of uninsured, so there is a big economic ripple effect. Medicaid expansion will help to break this vicious cycle.

Advocates deserve much credit for building a winning coalition around the Medicaid expansion. The political maturity of this effort was impressive. The coalition included, among others, business leaders, health care providers, seniors organizations and a wide array of advocates reflecting different interest groups.

Instead of posturing and making impossibly purist demands, advocates used creativity in adjusting a plan specific to New Hampshire. Under the bipartisan bill, low-wage workers will be able to use federal Medicaid dollars to buy private health insurance. This is a bit unorthodox and requires a waiver from the federal government, but it allowed moderate Republicans to jump on board.

Since the New Hampshire Senate is controlled by Republicans, getting the majority in the Senate to support the Medicaid expansion was no easy task. This is particularly true because many on the right have built their 2014 political platform on opposition to Obamacare. The Medicaid expansion is an essential element of Obamacare.

There is much to learn from the success of advocates in this effort. As a longtime progressive and a reader particularly of the progressive and left-wing blogosphere, I am used to seeing the glass-half-empty perspective. Obamacare is not single-payer national health insurance. So many gnash their teeth and bemoan that.

From my past experience, many of the bemoaners are removed from the legislative process. It is easy to rail from the sidelines when you are not in the game. In my earlier life, when I worked as a legal aid lobbyist, I was always impressed by the persistence and determination of my typically more conservative opponents. Many of the business lobbyists practically seemed to live at the Legislature 24/7. That was in stark contrast to progressives, who were often MIA. I used to think my side could learn from the conservative forces who did not give up and go cry in their beer. You could always count on the conservatives to be there, even when they were losing.

I think you can see the Medicaid expansion from the glass-half-full perspective. True, everyone is not covered, but this is the biggest advance I have seen in many a moon. The reform sets the stage for further advances toward universal coverage.

I hope the New Hampshire example can influence other states to follow our lead. When the U.S. Supreme Court affirmed the constitutionality of the Affordable Care Act in 2012, it gave states an option of expanding Medicaid. With New Hampshire as the newest addition, 26 states have now signed on.

However, that leaves 24 other states that have not opted for the Medicaid expansion. Six of them, including Maine, are considering it. The New Hampshire example may offer a way forward for those states on the fence or currently balking.

An irony of the Medicaid expansion is that the states refusing expansion would benefit the most from it. They include all the southern states as well as some heartland and Rocky Mountain states. We are talking 5 million poor uninsured adults who will lack coverage because their state did not opt for Medicaid expansion.

There is a gap in coverage between current Medicaid eligibility and the lower limit of those Obamacare recipients who would get subsidized insurance through the federal marketplace. To be more specific, of the 5 million people who live in states that have not opted to expand Medicaid, about 20 percent of that group resides in Texas, 16 percent in Florida, 8 percent in Georgia and 7 percent in North Carolina.

A recent Gallup poll shows that the Southern states are where residents are struggling the most to afford health care. I guess the other side of Southern hospitality toward strangers is meanness toward your own residents. You can be sure that the governors and legislators in the South who are blocking this advance have fine medical insurance coverage for themselves.

The Medicaid expansion will inject hundreds of millions of dollars in federal funds into New Hampshire’s economy. It will allow low wage workers to spend money on other critical needs like housing, food and utilities. This should be a direct benefit for local businesses.

As more states like New Hampshire enact the Medicaid expansion, it will put more pressure on the states that had initially opted out to reverse course. Their residents will see the benefit and will want it for themselves. The course of change is usually not a straight shot. It is more circuitous, and Medicaid expansion is no exception.

(Jonathan P. Baird of Wilmot is an administrative law judge. His column reflects his own view and not that of his employer, the Social Security Administration.)


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