As has been documented numerous times on this website, the Affordable Care Act's coverage gap has been an awful reality facing millions of some of the lowest income Americans, for no better reason than political inconvenience.
The expansion of Medicaid, effective in January 2014, fills in historical gaps in Medicaid eligibility for low-income adults and has the potential to extend health coverage to millions of currently uninsured individuals. This expansion essentially sets a national Medicaid income eligibility level of 138% of poverty (about $27,000 for a family of three) for adults. The expansion was intended to be national and to be the vehicle for covering low-income individuals, with premium tax credits for Marketplace coverage serving as the vehicle for covering people with higher incomes. However, the June 2012 Supreme Court ruling made the expansion of Medicaid optional for states, and as of March 2014, 24 states did not plan to implement the expansion in 2014 (Figure 1).Already we are seeing this have a big impact on Americans and health services. But as long as states refuse to expand Medicaid what is there to do?
In states that do not expand Medicaid, nearly five million poor uninsured adults have incomes above Medicaid eligibility levels but below poverty and may fall into a “coverage gap” of earning too much to qualify for Medicaid but not enough to qualify for Marketplace premium tax credits. Most of these people have very limited coverage options and are likely to remain uninsured.
This is what I propose:
1. Lower the eligibility limit for the insurance premium subsidies to the Medicaid limit level, just in the states that refuse to expand Medicaid.
2. Re-open enrollment, including for people who previously qualified for subsidies but did not enroll for whatever reasons.
Sure, such moves may be political difficult to achieve. But to help millions of Americans, it is well worth trying. And since when has that stopped us from trying to do any of the things we wanted to do?
Look, I understand that there were original justifications for the limit on subsidy eligibility that have led to the coverage gap. I don't know that I ever agreed with them, but I understand why we put them in place. However, we have to look at the reality of the situation, which is that these justifications have led to millions of Americans stuck in a coverage gap, some who are most in need of this care, or this government assistance. This gap wouldn't exist without GOP obstruction; there must be some meechanism to fix this problem that doesn't rely on the very same GOP obstructionists.
And the GOP are bound to scream bloody murder about the additional costs these subsidies would be to American taxpayers; except that cost is already largely mitigated by the fact that this cost was already largely accounted for in the Medicaid expansion.
And thanks to the initial enrollment period's success (exceeding the CBO targets), there is hardly anything to fear from the Insurance company side. Insurance companies have already got their healthy enrollees; any more is just more money in their pockets.
And besides, the benefits of this move could resonate beyond just the Americans in the coverage gap.
Here is my reasoning for making this change:
1. It uses GOP political moves against them.
The GOP, and in particular the GOP-controlled state legislatures who rejected the Medicaid expansion, are wholly responsible for this coverage gap, and purely for political reasons. In addition, many of these same states refused to set up their own state exchanges, forcing the federal government to scramble to set up the Healthcare.gov website, leading to the rollout debacle that hurt Democrats so much in the polls.
By making this change, it makes all those hoops the GOP jumped through essentially moot. Much like the 50-some House votes to repeal Obamacare. Much like the government shutdown. All that additional burden you placed on your state's citizens, hey, it doesn't even pay off politically. Republicans will be stuck with another Bowe Bergdahl.
Secondly, it puts Republicans in stark contrast to their political ideology. What are they gonna do in the face of another enrollment, change their minds and expand Medicaid? They're going to abandon the private insurance companies for single-payer? Good luck figuring that one out, Republicans.
In addition, thanks to the initial healthcare.gov rollout hiccups, it is working much better now, and we also have a better idea of what to expect if another enrollment were to open up. Likely, another huge initial surge. But the chances of it being handled better technically are much higher this time around. In one way, these states' refusal to open up their own insurance exchanges makes it far more technically feasible to open up enrollment again, since it will likely center on the Healthcare.gov website which has already faced its trial by fire. Well, maybe some software-side people can chime in with comments and elaborate on how much easier that makes it. But they've done it before.
Furthermore, by opening up another unscheduled enrollment period, Democrats are sure to open themselves up to attacks by the GOP that this is just an empty ploy to improve their chances for the November elections. However, the Democrats can easily say, look, we never would have had to do this if you guys had expanded Medicaid like the other states. And it has been enough time that we can document and objectively measure how this affects the states.
Finally, much of the GOP strategy for attacking the Affordable Care Act centered on the CBO estimates for enrollment, and whether that target would be met was surely a huge opening for them. But now that we have not only met that target but exceeded it, many of the attacks they previously used now ring hollow. Not enough people will enroll? Not enough young people will enroll? They already have.
2. Executive Order.
How would we actually go about implementing this change? One way would be to introduce legislation in Congress, as an offer to fix an apparent problem in how the ACA works. Surely, it would be another chance for Democrats in vulnerable districts to use their support of fixing the ACA in their political messaging. Maybe it wouldn't even be so intractable as it initially looks; Republicans have largely given up their fight against the ACA and moved on to other issues. And it's a chance to tell Congressional GOP not named Cruz, hey, here's your chance to help your state-level comrades out of the hole they have dug themselves into with the Medicaid expansion refusal.
But I have a better idea: Have President Obama issue an Executive Order, both implementing the subsidy eligibility change, and opening Enrollment.
What are the GOP gonna do to stop him, sue him? Oh wait, they already are. What does Obama have to lose now? If anything, this is yet another chance to embarrass his opponents. Logically, if Obama now uses an Executive Order to change the eligibility, Boehner and his cohorts would be sure to target it specifically. To their peril.
In other words, it gets to shift the narrative the GOP loves to use so much. Any chance they get, they love to scream that Obama is taking away people's insurance. However, if eligibility is opened through Executive Order, and then Boehner's lawsuit reverses that, then it will fall squarely on the Republicans. They are the ones who are now taking affordable care away from millions of Americans.
3. It's the right thing to do.
Look, I am not going to deny that the primary motivations, for me, is primarily the political impact this would have. Republicans are on the ropes when it comes to combatting the ACA; that's no reason to give them any breathing space. If it is at all possible to ride the ACA to a Democratic wave for 2014, then we should by all means aim for it.
But regardless of the political motivations, helping out the people who are stuck in the current coverage gap is obviously the right thing to do. These people deserve affordable care just like anyone else; that their plight is being politicized doesn't change this ultimate truth.
After all, it could also be seen as a political advantage to leave the coverage gap open, to highlight the differences between the red states who chose to reject the Medicaid expansion, and the blue states who chose to accept it, for example.
But I would rather we close that gap somehow, because at the end of the day, politics is only as valuable as the progress it helps us to achieve. And if politics is getting in the way of doing the right thing - in this case, providing needy people with affordable care - then how much better are we really being than the GOP?
Sure, by lowering the eligibility limit, and thus removing an incentive to expand Medicaid, this can be seen as a betrayal of Liberal ideals. But so is leaving people without access to affordable care. Let's not treat earning enough to fall into this gap as some sort of moral failing. The ACA is originally an ideological compromise; fixing it is going to be as well.
Of course, President Obama cannot be as transparent about his political motivations as I am. But above all else, he can point to this moral failing as justifications for an Executive Order.
The coverage gap can be - but most importantly, should be - closed. Might as well make it work to our political advantage while we're at it.