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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).

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.

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?

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 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 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 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.

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Comment Preferences

  •  Tip Jar (8+ / 0-)

    "In a country well governed, poverty is something to be ashamed of. In a country badly governed, wealth is something to be ashamed of.” -Confucius

    by pierre9045 on Thu Jun 26, 2014 at 07:46:01 AM PDT

  •  Excellent idea! (2+ / 0-)
    Recommended by:
    pierre9045, worldlotus

    I have a friend whom I will share this with!

    It would go a long ways towards covering those who have nothing right now.

    We have it within our power to make the world over again ~ Thomas Paine

    by occupystephanie on Thu Jun 26, 2014 at 08:24:40 AM PDT

  •  I'm scared to death (2+ / 0-)
    Recommended by:
    liberaldad2, colbey

    My SSDI puts me at 141% of "poverty level" for a single person, so when Mass. finally gets its act together, will I be booted all the way from fully covered by the state to having to pay my entire insurance out of my monthly, hardly munificent, SSDI?  I'm on SSDI because I have major ongoing health problems, providing myself with adequate insurance in this high-cost state will not be cheap.

    Pay no attention to the upward redistribution of wealth!

    by ActivistGuy on Thu Jun 26, 2014 at 09:35:20 AM PDT

    •  I don't know much about Mass's program (0+ / 0-)

      specifically, and how it changes under the ACA.

      Maybe this website might help.

      MassHealth is likely to change in these ways:

          A MassHealth expansion will allow adult residents under age 65, with or without children, with incomes no greater than 133%* of the Federal Poverty Guidelines (FPG), who are not otherwise eligible for MassHealth Standard or CommonHealth, to qualify.
          Note: The new MassHealth eligibility rules use a 133% FPG income limit and a 5% income disregard. In effect, this makes the income limit equal to 138% of the FPG. See How will income be counted? for details.
          Many residents who now have MassHealth Basic or Essential, as well as residents who have coverage through Commonwealth Care, the Medical Security Plan, and the Insurance Partnership, will qualify under the MassHealth expansion.
          People who are now excluded from MassHealth or other government subsidized insurance because of employment status, college attendance, or access to other insurance will no longer be excluded for those reasons.

          Benefits equivalent to MassHealth Standard coverage will be available to 19 and 20-year olds, long-term unemployed Department of Mental Health clients, individuals who are HIV+, and individuals receiving treatment for breast or cervical cancer* who meet the 133% FPG income limits and other eligibility requirements.
          *Note: Individuals in the Breast and Cervical Cancer Treatment Program with incomes 134%-250% FPG will continue to receive MassHealth Standard coverage in 2014.

          HIV+ individuals with incomes 134%-200% FPG will continue to be eligible for Family Assistance in 2014. This policy may change in the future.
          A new MassHealth coverage type called CarePlus will be available to other adult citizens and qualified noncitizens with incomes no greater than 133% of the Federal Poverty Guidelines. See CarePlus below.

      Note: Massachusetts residents with incomes no greater than 400% of the FPG who do not qualify for MassHealth due to income limits or immigration status may be eligible for government tax credits and subsidies to help pay for Qualified Health Plans purchased through the state's Health Connector. See Qualified Health Plans below.

      Does any of that seem relevant?

      "In a country well governed, poverty is something to be ashamed of. In a country badly governed, wealth is something to be ashamed of.” -Confucius

      by pierre9045 on Thu Jun 26, 2014 at 12:50:01 PM PDT

      [ Parent ]

  •  More corporate welfare? (0+ / 0-)

    It's the wrong way to fix it -- by throwing public funds at private entities you only strengthen the immoral for-profit health care system.  Truly fixing the system is to disempower the insurance corporations and move toward health care as a right.

    Hillary does not have the benefit of a glib tongue.

    by The Dead Man on Thu Jun 26, 2014 at 09:47:23 AM PDT

    •  That's a long term goal. (3+ / 0-)
      Recommended by:
      pierre9045, JamieG from Md, colbey

      In the short term, there are millions of people who are without health care and immediate help is critical.  

      To deny people health care is not going to move us closer to single payer.  

      •  But you are extending that long term (0+ / 0-)

        even more by this "fix" by further entrenching and enriching the insurance corporations.  It's the kind of short term thinking emblematic of wall street with their focus on quarterly profits even to the point of "killing the golden goose."

        Hillary does not have the benefit of a glib tongue.

        by The Dead Man on Thu Jun 26, 2014 at 10:49:23 AM PDT

        [ Parent ]

        •  Tell that to the people without health care. (3+ / 0-)
          Recommended by:
          pierre9045, penelope pnortney, colbey

          This was my argument in 2009, 2010.  Those of us who are/were without health care should not be made to suffer, waiting for another generation to get their act together on single payer.    

          ACA will slowly move people away from reliance on employer-based health care and eventually move toward single payer.  

          I'm afraid a Wall St. analogy does not quite fit the situation for Americans who have no access to affordable health care.  Closing the gap is not an ideological fix:  remember there would have been no gap if SCOTUS hadn't made it voluntary to extend Medicaid.  You are just punishing people if you don't extend some kind of fix to people whose Republican legislatures and Governors are making them suffer.  

        •  I don't think you are alone (0+ / 0-)

          in this thinking. And I don't think you are wrong for feeling this way.

          While most of us here are committed to combatting things like corporate greed, what you are speaking against are very abstract concepts. On the other hand, people are very realistically being made to suffer because of these political games.

          Are people's lives worth scoring political points against your ideological enemies? If so, how are we any better than the GOP?

          Let's also not forget that every person that the Affordable Care Acts wins over to the side of affordable care for act, is one step closer to the universal health care you want so much.

          "In a country well governed, poverty is something to be ashamed of. In a country badly governed, wealth is something to be ashamed of.” -Confucius

          by pierre9045 on Thu Jun 26, 2014 at 12:17:13 PM PDT

          [ Parent ]

          •  It's not about "scoring points" it's about fixing (0+ / 0-)

            the systemic problems without making those same problems worse.  On the short term you may save some people, but you extend, and in some ways worsen the system for succeeding generations -- making their own struggle harder than it should be.

            Hillary does not have the benefit of a glib tongue.

            by The Dead Man on Thu Jun 26, 2014 at 12:34:19 PM PDT

            [ Parent ]

            •  Do you honestly think (0+ / 0-)

              that the fix I proposed would perpetuate or prolong the systemic problems that would worsen the situation for succeeding generations, substantially more than if we just keep going the way things are now? And can you explain why?

              "In a country well governed, poverty is something to be ashamed of. In a country badly governed, wealth is something to be ashamed of.” -Confucius

              by pierre9045 on Thu Jun 26, 2014 at 12:43:21 PM PDT

              [ Parent ]

          •  i admit i don't fully get it (0+ / 0-)

            the whole "coverage gap" thing.  is it that Medicaid will now cover people who earn up to 138% of the FPL, but only in states that...decide that will be okay?  because previously, you could only be below the FPL to qualify for Medicaid?

            and then subsidies to buy insurance thru the ACA kick in if your income is above 138% of the FPL to...some much higher percentage of the FPL, at which point you don't get any help paying your premiums?

            in states that approved this, the government is...paying the subsidy for those between 99% and 138% of FPL?  right now the fed govt is paying it, but eventually the states will have to cover that amount for their citizens?

            but that last paragraph can't be right, because i think that's what you're suggesting be done now.

            so, what is the excuse the republicans in the 24 states use to deny this expansion?  (i know they use something about their state won't be able to afford it in 2-3 years when the feds stop paying...something.)

            or do i have the whole thing wrong?

            •  You pretty much get it (1+ / 0-)
              Recommended by:
              is it that Medicaid will now cover people who earn up to 138% of the FPL
              This is what is known as the Medicaid expansion. Before ACA, states all had a different cutoff.
              To be eligible for coverage, a person has historically had to satisfy two tests: belonging to a "categorically" eligible group (generally: children, pregnant women, parents, blind or disabled persons, and the elderly); and meeting the financial test set by the state for that group. Prior to the ACA, the federal government already mandated that eligibility levels for children and pregnant women be at least 100-133 percent (see table below), but eligibility levels for parents could be much lower, and states were not required to cover adults without dependent children at all.
              Also see here for a table of elibility levels set by the states (Table 1).
              but only in states that...decide that will be okay?
              Yes. When the Supreme Court ruled that the ACA was constitutional, they also ruled that states could opt out of expanding Medicaid.
              and then subsidies to buy insurance thru the ACA kick in if your income is above 138% of the FPL to...some much higher percentage of the FPL, at which point you don't get any help paying your premiums?
              Correct. See here for tables of subsidy as your income changes.
              in states that approved this, the government is...paying the subsidy for those between 99% and 138% of FPL?  right now the fed govt is paying it, but eventually the states will have to cover that amount for their citizens?
              Not quite. These are the people who are supposed to be eligible for Medicaid. However, there was no provision for the people in states that did not expand Medicaid to receive subsidies to purchase their insurance on the marketplace. This is known as the "Coverage Gap."
              but that last paragraph can't be right, because i think that's what you're suggesting be done now.
              Yes. This is essentially what I am proposing be done with this post. I am not an expert though, so I cannot say with 100% confidence that it would do what I say and it can be done how I said it could be done.
              so, what is the excuse the republicans in the 24 states use to deny this expansion?  (i know they use something about their state won't be able to afford it in 2-3 years when the feds stop paying...something.)
              Also, the general Republican ideologies - in effect, poor people should suffer. Other than that, there is no reasonable justification for the Republicans (who control these states' legislatures and/or Governors) to refuse the Medicaid expansion. The federal government covers the Medicaid Expansion 100%.
              The federal government will finance the great majority of the costs associated with the Medicaid expansion. For the "newly eligible population" (anyone not previously eligible in their state), the federal government will cover 100 percent of costs in 2014-16, and it will always cover at least 90 percent of the costs of this population. States will continue to receive their standard federal contributions for "traditionally eligible" populations. This amount is different from state to state, and averages less than 60 percent.
              So yes, when people here say that Republicans in these states are making their own citizens suffer for no better reason than politics, they are absolutely correct.

              Hope this helps.

              "In a country well governed, poverty is something to be ashamed of. In a country badly governed, wealth is something to be ashamed of.” -Confucius

              by pierre9045 on Fri Jun 27, 2014 at 06:14:44 AM PDT

              [ Parent ]

              •  thank you -- that helped a lot (1+ / 0-)
                Recommended by:

                obviously, i didn't have to get insurance thru the exchange.  i tried to help a friend (tried to convince her to sign up) but doing that didn't really help me understand all this.  except that right at the end, i realized they might NOT get subsidy help if their income was so low they fell in that gap.

                anyway, i was wondering why obama/the dems couldn't just change the Medicaid eligibility limit, rather than lowering the subsidy cut-off limit.  that would have helped with the "let's not push more people to the private insurance companies" thing.

                but now i get it--that's exactly what they originally tried to do, but what the SC said couldn't be mandated.
                i kinda wonder why not--i mean, it's the FEDERAL poverty level, and Medicaid is a FEDERAL program, so i don't understand the whole rationale (from earlier) that each state can set their own income limit/s.  must be because the state has to pay for part of the Medicaid.

                but thank you.  and while i don't like the private insurance companies getting more federal welfare (in essence), i like your suggestion because...of the reasons you've given.  and yes, let's help people now, and keep working on single-payer.  hopefully there will continue to be a push for that anyway.

  •  Why all this effort to force everyone into (0+ / 0-)

    the "UNSUREance" market's grubby hands?

    I'm just a dumb LPN in a doctors' clinical practice, who is watching the magic unfold. The fundamental bomb in the soup is that all this is happening through the chicanery of the giant UNSUREance cartel, the one that is so very pleased to take your premiums and collect and collate and transfer and share and sell all your private medical information and Big Data bits, and leaves you UNSURE of what your coverage actually is, UNSURE if they won't just arbitrarily deny coverage for treatment and medications, UNSURE if you can get the attention of (let alone redress from) anyone in hiding behind those complex documents and the phone trees that end up either disconnecting you, or letting you speak to someone who starts the conversation "Department of Denial, how may I not help you?"

    Dare one say it? Lest we forget, "Obamacare's" not perfect. Not by a long chalk. And there seems to not be a large line-up of possible "amendments" (remember? the ACA was 'the best we could do, we'll fix it later'?) to deal with the fundamental problems.

    To that list, one might add the following article (it's from Naked Capitalism, so get any dismissive digs in early) to the reading list:


    The Truth about Electronic Health Records

        Propaganda only works for so long. Pretty soon truth catches up to it. This is exactly what’s happening with electronic health records.

        If you’re a doctor you know how bad the government-mandated electronic health record (EHR) is. But if you’re a patient, you may not realize that EHRs are endangering your life and jeopardizing medical excellence.

        The EHR is nothing like what Big Government, Big Data, and Big Health said it would be. They promised convenience, coordinated care, fewer medical errors, more efficient medical practice, and portable medical records. They never meant it and it hasn’t happened. These data systems were created for billing, data collection and government control of doctors, not patient care.

    "The Ugly Truth About Electronic Health Records,"

    Please, if you care about your health and don't want to get "the treatment," read on, and keep paper records of your medications, history and labs and imaging and treatments, organize your "explanations of benefits," keep copies of all payments made. If you are physically and mentally able. Those magical EHRs can kill you. I do have stories of how that can work...

    Yeah, the Narrative here is mostly all in favor of the Victory of Obamacare in getting past the Red Menace of Repeal and in "signing up all those people." But as a lowly nurse in a clinical practice, I do get to see how the New is doing some big damage to what one would suppose to be the important parts of the Old, like the notion that doctor-patient relationships are about "patient care," and not feeding an insatiable insurance bureaucracy to try to stay afloat.

    Don't let's just pat ourselves on our triumphant backs about this piece of legislation -- so many of us did, and still do, be triumphant about Obamacare, and about the election of Barack Obama on the Hope and Change platform. "Implementation," from my and my doctors' perspective, let alone the patients who are finding out what it costs them in money and peace of mind and continuity of care, is for many a cruel joke, a series of nightmares. And since my doctors practice in two hospitals as well as in their office clinic, they have three (3) incompatible Electronic Health Record systems to try to deal with, and so do us shlubs who have to work double tides to try to keep the whole idiot thing in operation, for the benefit of our patients and of course those who profit from the privatized model, who depend on (but don't pay) us trench fighters to keep in all going. Having to deal with stuff like what's reported here, is such a blast, right?

    Add that to the infinite complexity of the effing UNSUREance mazes, "Press 1 for the Department of Denial Department, your call is very important to us if you don't want anything from us," and you have patients, our fellow humans, that so many actual health care people work so damn hard to, you know, care for, getting gutted and slammed by all the Wonders of Privatized National Forced Health UNSUREance. UNSURE of who your providers are or will be, UNSURE of what's covered, UNSURE whether you will be forced to "trial" cheap meds for a condition on which you have long been stable on more costly but effective med, UNSURE whether the REAL "death panels," the "utilization review" and "formulary decider" ghosts in the insurance companies will mark you for their attention, on and on...

    This last bit will likely get me written off as just another loony crank, but this stuff matters to me and a lot of others similarly situated:

    As a footnote, as a disabled vet who still has to work to eat, I get VA health care. Is it "single payer" or something else? Who cares? I have a little experience as provider and patient in most medical care settings. The VA system, despite the overload and underfunding that the assholes who are bringing you yet another Forever War reprise in Iraq (is Vietnam next? a do-over for the neo-cons there too?) have imposed, is way "better than average," costs are controlled, meds are cheap. Believe it or not, by the way, patients, PEOPLE, die while on the list for appointments with private primary cares and specialists and even hospitals, it's just the nature of life, as we have formed it here and as actuarial reality and statistics sort of mandate. But while "it's not perfect," it's a whole lot better than what I have seen in both for-profit and those fraudulently named "not-for-profit" hospitals.

    So for all the ACA cheerleading, who's leading on to something better? For comparison, Iraq under Saddam had universal and excellent health care, that dirty dictatorial socialist monster that he was. Boy, we sure have fixed that situation, now haven't we? Fixed it so good that there's likely not even a prayer that there will be a "nation" called Iraq in pretty short order. So guys like me can get back to our flashbacks and nightmares and fears that we will be "called up" and have to go serve the Empire once again... While some at home have pleasant dreams of the Victory of Obamacare...

    "Is that all there is?" Peggy Lee.

    by jm214 on Thu Jun 26, 2014 at 12:27:36 PM PDT

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