tag:theconversation.com,2011:/au/topics/medicaid-expansion-32025/articlesMedicaid expansion – The Conversation2023-05-08T12:17:57Ztag:theconversation.com,2011:article/2047312023-05-08T12:17:57Z2023-05-08T12:17:57ZMedicaid work requirements would leave more low-income people without health insurance – but this policy is unlikely to pass this time around<figure><img src="https://images.theconversation.com/files/524627/original/file-20230505-6263-k3g9u0.jpg?ixlib=rb-1.1.0&rect=55%2C7%2C5230%2C2868&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Speaker Kevin McCarthy got the House to approve a package that could reduce the Medicaid program's scale.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/house-speaker-kevin-mccarthy-speaks-about-the-countrys-debt-news-photo/1463574682">Alex Wong/Getty Images</a></span></figcaption></figure><p><em>The legislative package the U.S. <a href="https://www.congress.gov/bill/118th-congress/house-bill/2811/text">House of Representatives passed on April 26, 2023</a>, by a narrow margin would pare federal spending over the next decade while also <a href="https://theconversation.com/why-america-has-a-debt-ceiling-5-questions-answered-164977">raising the debt ceiling</a>. One important measure in the Republican-backed bill would restrict access to Medicaid for millions of Americans.</em></p>
<p><em>About <a href="https://theconversation.com/1-in-4-americans-are-covered-by-medicaid-or-chip-a-program-that-insures-low-income-kids-176424">1 in 4 Americans have health coverage</a> through the program, which primarily serves low-income and disabled people and which is <a href="https://doi.org/10.1215/03616878-2882219">funded jointly by the federal government and the states</a>. Should the Republican-backed legislation prevail, the federal government would require <a href="https://apnews.com/article/senate-hearing-debt-ceiling-bae2b777086b0e232cc0d51fe03a3930">adults insured by Medicaid who are 19 to 55</a> years old and don’t have children or other dependents to spend 80 hours a month doing paid work, job training or community service.</em></p>
<p><em>The Conversation asked <a href="https://scholar.google.com/citations?user=QY68LSIAAAAJ&hl=en&oi=ao">Simon F. Haeder</a>, a public health scholar, to explain what the proposed work requirements would do and why the <a href="https://apnews.com/article/medicaid-enrollees-removed-review-health-insurance-pandemic-bffc3c67ab2767e4e3cea8250683ea7a">Republican effort to institute them matters</a> for the millions of Americans who rely on Medicaid.</em></p>
<h2>What would change if this policy took effect?</h2>
<p>Unlike some other government programs that assist low-income Americans, including the <a href="https://theconversation.com/snap-work-requirements-dont-actually-get-more-people-working-but-they-do-drastically-limit-the-availability-of-food-aid-204257">Supplemental Nutrition Assistance Program</a>, or SNAP, and <a href="https://www.acf.hhs.gov/ofa/programs/temporary-assistance-needy-families-tanf">Temporary Assistance for Needy Families</a>, Medicaid currently has no work requirements.</p>
<p>The package the House recently passed would require all states to implement this policy. <a href="https://www.cbo.gov/system/files/2023-04/59109-Pallone.pdf">An estimated 15 million Americans</a> with Medicaid would need to comply with the requirements.</p>
<p>This change would dramatically increase bureaucratic hassles for Medicaid beneficiaries who are disproportionately low-income, disabled and nonwhite. KFF, a health care research nonprofit, <a href="https://www.kff.org/medicaid/issue-brief/tough-tradeoffs-under-republican-work-requirement-plan-some-people-lose-medicaid-or-states-could-pay-to-maintain-coverage/">estimates that 1.7 million</a> people would lose federal coverage. However, states have the option to continue to pay for these individuals solely with state funds.</p>
<p>Those who would be subject to the new rules would not be the only ones at risk. It is well known that many of the exempt populations, including the aged and disabled, <a href="https://www.milkenreview.org/articles/tangled-up-in-side-effects">struggle to complete paperwork</a> or fail to understand complex bureaucratic rules. Many experts predict that coverage losses could be <a href="https://doi.org/10.1056/NEJMsr1901772">even higher among these demographics</a>, as states would consider them to be out of compliance with work requirements. </p>
<h2>Are there precedents for this policy?</h2>
<p>This is <a href="https://www.milkenreview.org/articles/tangled-up-in-side-effects">not the first time</a> that Republicans sought to make access to Medicaid contingent on meeting work requirements for at least some beneficiaries. The Trump administration worked with various Republican-led states to use what are known as <a href="https://www.kff.org/medicaid/issue-brief/the-landscape-of-medicaid-demonstration-waivers-ahead-of-the-2020-election/">1115 demonstration waivers</a> for that purpose. These waivers allow states to make temporary changes to their Medicaid programs that depart from certain statutory requirements. However, those efforts were <a href="https://www.kff.org/policy-watch/medicaid-work-requirements-at-u-s-supreme-court/">quickly blocked in court</a>. Most were never even piloted before the Biden administration rescinded them.</p>
<p>One exception is Arkansas. </p>
<p>Arkansas began imposing work requirements on Medicaid recipients on adults ages 30 to 49 starting in June 2018. As a result, about <a href="https://www.cbpp.org/research/health/states-experiences-confirm-harmful-effects-of-medicaid-work-requirements">1 in 4 Arkansans</a> subject to that policy ended up <a href="https://www.doi.org/10.1056/NEJMsr1901772">losing their coverage by the end of that year</a> before <a href="https://www.kff.org/medicaid/issue-brief/an-overview-of-medicaid-work-requirements-what-happened-under-the-trump-and-biden-administrations/">courts deemed it unlawful</a>.</p>
<p>The <a href="https://theconversation.com/medicaid-work-requirements-where-do-they-stand-after-the-blue-wave-107762">Arkansas experience</a>, which was particularly burdensome for beneficiaries, reaffirmed many concerns of those who oppose work requirements. Importantly, the reason many lost coverage was not that they failed to complete the required hours of paid work, job training or community service, but that they struggled to <a href="https://abcnews.go.com/Health/wireStory/congress-eyes-work-rules-millions-covered-medicaid-98967684">overcome bureaucratic challenges</a>.</p>
<p>Efforts are also underway in <a href="https://www.commonwealthfund.org/blog/2023/far-reaching-implications-georgia-medicaid-work-experiment">Georgia to impose work requirements</a> on Medicaid beneficiaries despite legal hurdles and the Biden administration’s objections. With President Joe Biden in office, it’s going to remain difficult to experiment with this policy unless Congress approves a measure like the one in the House package.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/524626/original/file-20230505-17-jus7is.jpg?ixlib=rb-1.1.0&rect=71%2C58%2C2910%2C1886&q=45&auto=format&w=1000&fit=clip"><img alt="A white woman with short brown hair with her hands holding her face looks sad." src="https://images.theconversation.com/files/524626/original/file-20230505-17-jus7is.jpg?ixlib=rb-1.1.0&rect=71%2C58%2C2910%2C1886&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/524626/original/file-20230505-17-jus7is.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=392&fit=crop&dpr=1 600w, https://images.theconversation.com/files/524626/original/file-20230505-17-jus7is.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=392&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/524626/original/file-20230505-17-jus7is.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=392&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/524626/original/file-20230505-17-jus7is.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=493&fit=crop&dpr=1 754w, https://images.theconversation.com/files/524626/original/file-20230505-17-jus7is.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=493&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/524626/original/file-20230505-17-jus7is.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=493&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Elizabeth Cloinger lost access to Medicaid in Arkansas despite her eligibility when the state adopted work requirements.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/elizabeth-cloinger-was-tossed-off-of-the-arkansas-works-news-photo/1175367574?adppopup=true">Michael S. Williamson/The Washington Post via Getty Images</a></span>
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</figure>
<h2>What would be different this time?</h2>
<p>States had to actively seek out those waivers that Republicans embraced when former President Donald Trump was in the White House. That meant that Medicaid beneficiaries in states with Democratic leadership, such as California, were unlikely to ever confront them. </p>
<p>The proposed changes in the <a href="https://www.congress.gov/bill/118th-congress/house-bill/2811/text">House legislation would force all states</a> to implement work requirements for adults from 18 to 55 without dependents. Failure to comply would put states at risk of losing federal funding, so even Democratic-led states would have to adopt these rules. The proposed changes would also circumvent many of the legal concerns that previously prevented the widespread implementation of Medicaid work requirements.</p>
<p>Importantly, this policy change would coincide with <a href="https://osf.io/xzaf4">ongoing upheaval for Medicaid beneficiaries</a>. This is because millions of Medicaid beneficiaries are already losing coverage because of the expiration of the COVID-19 <a href="https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-the-unwinding-of-the-medicaid-continuous-enrollment-provision/">public health emergency declaration</a> on May 11 and states’ restarting eligibility determinations of Medicaid beneficiaries <a href="https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-the-unwinding-of-the-medicaid-continuous-enrollment-provision/">on April 1</a>. As long as the government’s continuous enrollment policy was in effect, <a href="https://osf.io/xzaf4">states couldn’t kick anyone off of Medicaid</a>.</p>
<p>The number of people covered by the program soared to <a href="https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html">93 million as of January 2023</a>.</p>
<p><iframe id="ELIcj" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/ELIcj/1/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<h2>Is this policy compatible with the purpose of Medicaid?</h2>
<p>The point of Medicaid has always been providing eligible low-income people with <a href="https://www.ssa.gov/OP_Home/ssact/title19/1901.htm">access to comprehensive health coverage</a> for as long as they need it. That is, <a href="https://doi.org/10.1215/03616878-10637708">Medicaid is exclusively a health insurance program</a>.</p>
<p>Some other safety net programs are supposed to achieve multiple goals. For example, the official mission of <a href="https://www.acf.hhs.gov/ofa/programs/tanf/about">Temporary Assistance for Needy Families</a> is to “end the dependence of needy parents on government benefits by promoting job preparation, work and marriage,” rather than just to help those needy parents make ends meet.</p>
<p>At the same time, there is evidence that <a href="https://www.kff.org/medicaid/issue-brief/the-relationship-between-work-and-health-findings-from-a-literature-review/">Medicaid leads to greater workforce participation</a>, because it provides affordable health coverage as well as access to needed medical care. If you have an illness, it can be much easier to stay on the job if you’re getting the treatment your condition requires. Indeed, <a href="https://www.kff.org/medicaid/issue-brief/understanding-the-intersection-of-medicaid-work-a-look-at-what-the-data-say/">most able-bodied adults on Medicaid are employed</a>.</p>
<p>Ironically, pushing people off Medicaid, either for failing to fulfill work requirements or because they struggle with navigating the bureaucracy, would likely <a href="https://www.kff.org/medicaid/issue-brief/the-relationship-between-work-and-health-findings-from-a-literature-review/">reduce the number of people who work</a>.</p>
<h2>Why is this significant?</h2>
<p>It seems unlikely that Medicaid work requirements will become law in 2023 or 2024, because <a href="https://doi.org/10.1215/03616878-8802198">Democrats have steadfastly opposed</a> their implementation and the party commands a majority in the Senate. However, given the <a href="https://www.whitehouse.gov/cea/written-materials/2021/10/06/life-after-default/">potentially dramatic implications of defaulting on the federal debt</a>, some Democrats may be willing to compromise.</p>
<p>For now, I think it’s far more likely that the Republicans in Congress are setting the stage for future efforts to make more public assistance programs contingent on complying with work requirements, especially the next time a Republican becomes the president of the United States.</p>
<p>If measures like the one the House passed as part of the Republican debt-ceiling package were to become law, even states with entrenched Democratic leadership could have little recourse to fight back.</p><img src="https://counter.theconversation.com/content/204731/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder receives funding from the Robert Wood Johnson Foundation and the Commonwealth of Pennsylvania.</span></em></p>Adults insured by Medicaid who are 19 to 55 years old and don’t have children or other dependents would need to spend 80 hours a month doing paid work, job training or community service.Simon F. Haeder, Associate Professor of Public Health, Texas A&M UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1878172022-09-15T12:22:25Z2022-09-15T12:22:25ZIn states where abortion is banned, children and families already face an uphill battle<figure><img src="https://images.theconversation.com/files/482819/original/file-20220905-14-wr41ei.jpg?ixlib=rb-1.1.0&rect=21%2C26%2C3540%2C2344&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Of the 10 most child-friendly states, only one has attempted to ban abortion.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/katherine-merlos-a-pre-k-3-student-centron%C3%ADa-gives-a-thumbs-news-photo/1239430403">Sarah L. Voisin/The Washington Post via Getty Images</a></span></figcaption></figure><p>Some proponents of abortion bans and restrictions say they are concerned about “supporting not just life,” but what they call “<a href="https://missouriindependent.com/2022/07/06/states-with-strong-antiabortion-laws-have-high-maternal-and-infant-mortality-rates/">quality of life worth living</a>,” saying they want to <a href="https://www.theatlantic.com/politics/archive/2022/06/anti-abortion-movement-dobbs-roe-overturned/661393/">promote laws and policies that help families</a>. Three authors from Brigham Young University, for instance, have noted that the overturning of Roe v. Wade provides a “<a href="https://www.thepublicdiscourse.com/2022/06/82906/">genuine opportunity for pro-lifers to work with people of diverse political persuasions</a> to seek a more just and compassionate world. This world would be not only pro-life, but also pro-child, pro-parent and pro-family.”</p>
<p>U.S. Sen. Mitt Romney of Utah is one of three Republicans in the Senate who have sponsored a bill called the <a href="https://www.romney.senate.gov/romney-family-security-act-2-0-one-of-the-most-important-efforts-to-support-the-family-in-nearly-thirty-years/">Family Security Act</a>, billed as a “pro-family, pro-life and pro-marriage plan” that would provide a monthly cash benefit starting at pregnancy and continuing through the child turning 17.</p>
<p>But so far, these are <a href="https://www.theatlantic.com/politics/archive/2022/06/anti-abortion-movement-dobbs-roe-overturned/661393/">minority voices</a> in the anti-abortion movement. </p>
<p>As a law professor who <a href="https://scholar.google.com/citations?user=gCJEShUAAAAJ&hl=en&oi=ao">studies reproductive care</a>, policies that affect families and political partisanship, I have been following the relationship between <a href="https://www.urban.org/urban-wire/research-shows-access-legal-abortion-improves-womens-lives">abortion restrictions and family well-being</a> for decades. It turns out that states taking the strictest stands against abortion tend to have among the <a href="https://www.nytimes.com/2022/07/28/upshot/abortion-bans-states-social-services.html">worst statistics</a> on child and family well-being in the nation.</p>
<h2>Unintended pregnancy and infant mortality</h2>
<p>Take Mississippi, the state that enacted the abortion restriction law that was at the center of the Supreme Court’s June 2022 opinion in <a href="https://www.supremecourt.gov/opinions/21pdf/19-1392_6j37.pdf">Dobbs v. Jackson Women’s Health Organization</a>, which struck down federal protection for the right to get an abortion. </p>
<p>In 2019, Mississippi had the <a href="https://www.americashealthrankings.org/explore/health-of-women-and-children/measure/unintended_pregnancy/state/U.S">highest rate of unintended pregnancy</a>, defined as the percentage of women who recently gave birth but whose pregnancies were either <a href="https://www.cdc.gov/reproductivehealth/contraception/unintendedpregnancy/index.htm">unwanted or happened at an unwanted time</a>. In Mississippi, 47% of women who recently had a child did not want to become pregnant or wanted to become pregnant later in life.</p>
<p>By contrast, Vermont had the nation’s lowest rate of unintended pregnancy in 2019, with <a href="https://www.americashealthrankings.org/explore/health-of-women-and-children/measure/unintended_pregnancy/state/U.S">just 20% of women who recently had a child</a> saying they would have preferred not to get pregnant or wanted to do so at some point in the future. That state already protects abortion rights. If Vermont’s <a href="https://www.wcax.com/2022/06/23/will-vermont-become-abortion-haven-if-scotus-upends-roe-v-wade/">upcoming referendum on abortion</a> passes, the state’s constitution will protect “<a href="https://legislature.vermont.gov/Documents/2022/Docs/BILLS/PR0005/PR0005%20As%20adopted%20by%20the%20Senate%20Official.pdf">an individual’s right to personal reproductive autonomy</a>.”</p>
<p>Mississippi also has the <a href="https://www.cdc.gov/nchs/pressroom/sosmap/infant_mortality_rates/infant_mortality.htm">highest infant mortality rate</a> in the country. Five of the other nine states with the highest infant mortality <a href="https://www.nytimes.com/interactive/2022/us/abortion-laws-roe-v-wade.html">also have abortion bans</a>. At the other end of the spectrum, of the 10 states with the lowest infant mortality rates, <a href="https://www.cdc.gov/nchs/pressroom/sosmap/infant_mortality_rates/infant_mortality.htm">only one – Iowa</a> – has a law restricting abortions, <a href="https://www.kcci.com/article/governor-kim-reynolds-announces-legal-actions-regarding-abortion-in-iowa/40449729">although a court has prevented its enforcement</a>.</p>
<h2>Childhood poverty and teen birth rates</h2>
<p>Mississippi has the <a href="https://www.census.gov/acs/www/data/data-tables-and-tools/ranking-tables/">highest rate of child poverty in the country</a>. Six of the other 10 states with the country’s highest child poverty levels also have <a href="https://www.nytimes.com/interactive/2022/us/abortion-laws-roe-v-wade.html">abortion bans in effect</a>: Louisiana, Arkansas, Kentucky, Alabama, Oklahoma and Tennessee.</p>
<p>Mississippi also had the <a href="https://www.cdc.gov/nchs/pressroom/sosmap/teen-births/teenbirths.htm">highest teen birth rate in the country</a>, and eight of the other nine states with the highest teen birth rates also <a href="https://www.nytimes.com/interactive/2022/us/abortion-laws-roe-v-wade.html">ban abortions or have a ban blocked</a>.</p>
<p>In all 10 states with the lowest teen birth rates, <a href="https://www.washingtonpost.com/politics/2022/06/24/abortion-state-laws-criminalization-roe/">abortion is legal</a> and likely to be protected for the foreseeable future.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/482820/original/file-20220905-18-djghzt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A pregnant person has a written message on the skin of her belly: 'My daughter deserves a choice'" src="https://images.theconversation.com/files/482820/original/file-20220905-18-djghzt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/482820/original/file-20220905-18-djghzt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/482820/original/file-20220905-18-djghzt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/482820/original/file-20220905-18-djghzt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/482820/original/file-20220905-18-djghzt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/482820/original/file-20220905-18-djghzt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/482820/original/file-20220905-18-djghzt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">A pregnant activist calls for abortion rights in Chicago on June 25, 2022.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/pregnant-woman-takes-part-in-a-protest-in-downtown-chicago-news-photo/1241562432?adppopup=true">Vincent D. Johnson/Xinhua via Getty Images)</a></span>
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<h2>Supporting families</h2>
<p>The well-being of children also depends on the availability of support for their parents.</p>
<p>For instance, <a href="https://www.ncsl.org/research/labor-and-employment/state-family-and-medical-leave-laws.aspx">11 states plus the District of Columbia legally require employers</a> to offer workers paid time off after the birth or adoption of a child. None of those jurisdictions <a href="https://www.washingtonpost.com/politics/2022/06/24/abortion-state-laws-criminalization-roe/">bans abortions</a>.</p>
<p>Another federal effort to support families came in the Affordable Care Act, enacted in 2010, with <a href="https://www.healthcare.gov/glossary/affordable-care-act/">sweeping changes</a> to the nation’s health insurance marketplace. One provision allowed states to <a href="https://www.healthcare.gov/medicaid-chip/medicaid-expansion-and-you/">expand Medicaid eligibility</a> to more adults, with financial support from the federal government. If Medicaid were expanded, <a href="https://www.urban.org/research/publication/3-7-million-people-would-gain-health-coverage-2023-if-remaining-12-states-were">reproductive-aged women</a> would be among the groups to experience the largest coverage gains.</p>
<p>As of August 2022, <a href="https://www.urban.org/research/publication/3-7-million-people-would-gain-health-coverage-2023-if-remaining-12-states-were">12 states</a> had not adopted the expansion: Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin and Wyoming. <a href="https://www.nytimes.com/interactive/2022/us/abortion-laws-roe-v-wade.html">Eight of those states</a> have either a full ban on abortion or a ban after six weeks – before many people realize they are pregnant.</p>
<p>Two of those states, <a href="https://www.nytimes.com/interactive/2022/us/abortion-laws-roe-v-wade.html">South Carolina and Wyoming</a>, have abortion <a href="https://www.npr.org/2022/08/04/1115542013/wyomings-new-ban-on-abortions-has-been-temporarily-blocked">laws that are tied up in the courts</a>, and Florida bans abortions after 15 weeks. </p>
<p>In a June 2022 <a href="https://www.brookings.edu/blog/up-front/2022/06/30/the-end-of-roe-will-create-more-inequality-of-opportunity-for-children/">Brookings Institution study</a> of the states that are considered most child-friendly – measured by state expenditures per child and children’s overall well-being – the authors found that among the top 10, only Wyoming was <a href="https://www.nytimes.com/interactive/2022/us/abortion-laws-roe-v-wade.html">even trying to ban abortion</a>. For the 10 states Brookings rated least child-friendly, nine either had a trigger ban or other abortion restriction.</p>
<p>The overall pattern is clear: A strong social safety net and other anti-poverty programs <a href="https://www.nytimes.com/2022/07/13/opinion/abortion-romney-child-tax-credit.html">are more likely to be available</a> in states that also support abortion access, while actual measures of child and family well-being are often worse in states that restrict abortions.</p><img src="https://counter.theconversation.com/content/187817/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Naomi Cahn does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>States taking the strictest stands against abortion tend to have among the worst statistics in the nation on child and family well-being.Naomi Cahn, Professor of Law, University of VirginiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1767772022-02-24T13:53:50Z2022-02-24T13:53:50ZWhen parents get Medicaid, it can benefit the health of their kids too<figure><img src="https://images.theconversation.com/files/446819/original/file-20220216-14-18uvj8q.jpg?ixlib=rb-1.1.0&rect=59%2C81%2C4883%2C3297&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Millions of low-income Americans have gained health insurance through the Affordable Care Act.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/black-mother-with-baby-reading-pill-bottle-royalty-free-image/187137286">Ariel Skelley/DigitalVision via Getty Images</a></span></figcaption></figure><p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em></p>
<h2>The big idea</h2>
<p>Low-income parents who live in <a href="https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map">states that expanded their Medicaid programs</a> under the Affordable Care Act are 4.7% more likely to say they are in good health than their peers in states that have declined to take this step, according to new research I co-authored. </p>
<p>In addition, children of low-income parents living in states that have expanded their Medicaid programs have a 2% lower growth in <a href="https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm">body mass index</a>, suggesting improvement in their health as well. Preventing excessive weight gain for school-aged children is a priority due to linkages with <a href="https://doi.org/10.1542/peds.101.3.e5">adult obesity</a> and other <a href="https://doi.org/10.1016/j.ehb.2012.05.003">health concerns</a>.</p>
<p>These are the <a href="https://doi.org/10.1016/j.ehb.2021.101098">main findings from a study</a> <a href="https://scholar.google.com/citations?user=WxA-LzcAAAAJ&hl=en&oi=ao">I conducted</a> with <a href="https://scholar.google.com/citations?hl=en&user=6cbDgj0AAAAJ">Caitlin McPherran Lombardi</a> and <a href="https://scholar.google.com/citations?hl=en&user=wXzyv3oAAAAJ">Lindsey Rose Bullinger</a>.</p>
<p>After combing through <a href="https://nces.ed.gov/ecls/kindergarten2011.asp">nationally representative data</a>, we compared the health of parents and their children in states that had taken advantage of Medicaid expansion under the ACA with those living in states that had not. We also analyzed the changes before and after expansion took effect in the state where these parents lived.</p>
<p>We used statistical analysis to rule out other variables, such as race or ethnicity and marital status, as the source of these differences. We didn’t detect any significant changes in terms of what parents said about their children’s overall health or the use of preventive care. </p>
<h2>Why it matters</h2>
<p>In 2014, <a href="https://doi.org/10.1377/hlthaff.2015.1632">28 states expanded access to Medicaid</a>, a federal health insurance program primarily for low-income and disabled people under 65 that’s administered independently by every state. States that have expanded the program can enroll people with incomes up to 138% of the <a href="https://www.healthcare.gov/glossary/federal-poverty-level-fpl/">federal poverty level</a> – currently <a href="https://www.medicaidplanningassistance.org/federal-poverty-guidelines/">US$38,295 for a family of four</a> – as part of the Affordable Care Act. Since then, <a href="https://www.healthinsurance.org/medicaid/">another 10 states</a> have expanded access. Most recently, Missouri and Oklahoma expanded the program in 2021.</p>
<p>About <a href="https://www.kff.org/medicaid/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/">2.2 million uninsured adults under 65</a> who have incomes below the poverty line live in Texas, Florida, North Carolina and the other nine states that have yet to expand access to Medicaid. If they resided elsewhere, they would be able to enroll in the program.</p>
<p>Roughly 60% of the Americans in this situation in 2019 were <a href="https://www.cbpp.org/research/health/closing-medicaid-coverage-gap-would-help-diverse-group-and-narrow-racial">people of color</a>. <a href="https://www.kff.org/health-reform/issue-brief/build-back-better-would-change-the-ways-low-income-people-get-health-insurance/">Legislation that would further increase access</a> to health insurance has stalled in the Senate.</p>
<h2>What other research is being done</h2>
<p><a href="https://doi.org/10.1542/peds.2019-3178">Previous</a> <a href="https://doi.org/10.1016/j.whi.2017.11.005">studies</a> have <a href="https://doi.org/10.1002/pam.21993">shown</a> that Medicaid expansion is leading more low-income parents to get health insurance. Other researchers have also found that concerns about medical costs and health insurance coverage eased <a href="https://doi.org/10.1377/hlthaff.2016.1650">psychological distress</a> among low-income parents. </p>
<p>Children from low-income households were already eligible, prior to 2014, for government-provided heath insurance, <a href="https://www.census.gov/library/stories/2019/09/uninsured-rate-for-children-in-2018.html">either through Medicaid</a> or the <a href="https://www.medicaid.gov/chip/index.html">Children’s Health Insurance Program</a>. Known as CHIP, it’s a joint federal and state program that provides health coverage to kids and pregnant women whose families have low incomes but make too much to qualify for Medicaid.</p>
<p>But <a href="https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2017.0347">multiple</a> <a href="https://doi.org/10.1177/0046958020952920">studies</a> have found that increased awareness of public health insurance eligibility among parents led to an uptick in children’s insurance coverage as well in what is known as the “<a href="https://ccf.georgetown.edu/2017/09/15/medicaids-welcome-mat-effect-means-medicaid-expansion-helps-children-get-health-coverage/">welcome-mat effect</a>.” </p>
<p>These studies also echo the findings from prior studies of earlier expansions to Medicaid, which took place in the 1990s and 2000s. That research determined that <a href="https://doi.org/10.1111/1475-6773.00177">uninsurance rates</a> for children fell, and that newly insured low-income parents said they had increased their use of <a href="https://doi.org/10.1016/j.jhealeco.2005.03.007">preventive medical care</a> and reported significant <a href="https://doi.org/10.1111/1475-6773.12432">mental health improvements</a>.</p>
<h2>What’s next</h2>
<p>We are doing additional research regarding the benefits of Medicaid expansion. One study indicates that low-income children in Medicaid-expansion states <a href="https://www.edworkingpapers.com/ai21-406">made more progress in standardized reading tests</a> compared with kids their age in other states.</p>
<p>We’re also finding that low-income parents in states that expanded Medicaid spent about 13% more time reading with their children, and they were 5% more likely to have consistent dinnertime routines than their counterparts in states that haven’t taken this step.</p>
<p>[<em>Like what you’ve read? Want more?</em> <a href="https://memberservices.theconversation.com/newsletters/?source=inline-likethis">Sign up for The Conversation’s daily newsletter</a>.]</p><img src="https://counter.theconversation.com/content/176777/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maithreyi Gopalan receives funding from Spencer Foundation and the Population Research Institute that is funded by an infrastructure grant by the Eunice Kennedy Shriver National Institute of Child Health and Human Development. </span></em></p>Social scientists determined that body mass index growth declined for children of low-income parents in states that had expanded their Medicaid programs.Maithreyi Gopalan, Assistant Professor of Education and Public Policy, Penn StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1764242022-02-18T13:07:14Z2022-02-18T13:07:14Z1 in 4 Americans are covered by Medicaid or CHIP – a program that insures low-income kids<figure><img src="https://images.theconversation.com/files/447118/original/file-20220217-6550-13ekrf6.jpg?ixlib=rb-1.1.0&rect=319%2C31%2C4865%2C2491&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">More than 91% of the country has health insurance now.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/male-nurse-showing-digital-tablet-to-mother-by-royalty-free-image/1309071095">The Good Brigade/DigitalVision via Getty Images</a></span></figcaption></figure><figure class="align-center zoomable">
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<p>As of July 2021, a total of <a href="https://www.medicaid.gov/medicaid/national-medicaid-chip-program-information/downloads/july-2021-medicaid-chip-enrollment-trend-snapshot.pdf">83.6 million</a> Americans were insured through either Medicaid or the <a href="https://www.medicaid.gov/chip/index.html">Children’s Health Insurance Program</a>.</p>
<p>That’s almost 1 in 4 Americans, with 76.7 million insured through Medicaid and 6.9 million through CHIP. Both public health insurance programs are funded jointly by the federal and state governments. Medicaid provides health insurance for low-income people, <a href="https://www.census.gov/library/publications/2021/demo/p60-274.html">most of whom are 64 or younger</a>.</p>
<p>CHIP provides health coverage to kids and pregnant women whose families have low incomes but make too much to qualify for Medicaid.</p>
<h2>Affordable Care Act’s impact</h2>
<p>Before states began to expand Medicaid in 2014 as part of the Affordable Care Act, the program was much smaller, <a href="https://www.census.gov/content/dam/Census/library/publications/2015/demo/p60-253.pdf">covering around 55 million people in 2013</a>.</p>
<p>So far, <a href="https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map">38 states and the District of Columbia</a> have expanded Medicaid access, with financial support from the federal government. </p>
<p>Prior to the ACA, most states were more restrictive about who could enroll in Medicaid, a program launched following the enactment of landmark legislation President <a href="https://www.medicaid.gov/about-us/program-history/index.html">Lyndon B. Johnson signed into law in 1965</a>. After the ACA, the federal government began to shoulder more of the program’s costs, footing at least <a href="https://www.kff.org/medicaid/issue-brief/new-incentive-for-states-to-adopt-the-aca-medicaid-expansion-implications-for-state-spending">90% of the bill</a> for new enrollees covered through the program’s expansion.</p>
<p>Today, all adults in Medicaid expansion states who are under 65 with annual incomes less than <a href="https://www.medicaidplanningassistance.org/federal-poverty-guidelines/">138% of the federal poverty line</a> are eligible for Medicaid. In 2022, that means someone who is single without dependents and has an income of $18,754 or less qualifies, as does a family of four earning up to $38,295.</p>
<p>Eligibility rules in nonexpansion states vary widely and <a href="https://www.kff.org/medicaid/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/">exclude more low-income people</a>.</p>
<p>CHIP was <a href="https://www.medicaid.gov/about-us/program-history/index.html">signed into law in 1997</a>. Like the Medicaid expansion it was optional, yet it was <a href="https://www.macpac.gov/subtopic/history-and-impact-of-chip/">adopted in all states within three years, by 2000</a>.</p>
<p>Unfortunately, <a href="https://www.census.gov/library/stories/2021/09/uninsured-rates-for-children-in-poverty-increased-2018-2020.html">4.3 million</a> children remain uninsured, many of whom are in poverty, live in a nonexpansion state or a state with stricter <a href="https://www.medicaid.gov/medicaid/national-medicaid-chip-program-information/medicaid-childrens-health-insurance-program-basic-health-program-eligibility-levels/index.html">income eligibility standards for CHIP</a>.</p>
<p>Even when children are eligible for Medicaid or CHIP, they may not be enrolled in the program due to their parents’ lack of awareness or their state’s lack of outreach. </p>
<p>The pace of <a href="https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/">Medicaid expansion since 2014</a> has been far slower than the CHIP rollout. Twelve states have yet to opt in, as of February 2022, though the <a href="https://www.washingtonpost.com/politics/2022/01/31/south-dakota-is-next-front-medicaid-expansion/">expansion debate continues</a>.</p>
<p>And yet Medicaid’s sharp enrollment growth has reduced the share of uninsured people.</p>
<h2>Fewer uninsured Americans</h2>
<p>About <a href="https://www.census.gov/content/dam/Census/library/visualizations/2021/demo/p60-274/figureB1.pdf">91.4% of Americans had public or private health coverage</a> for at least part of 2020, leaving an estimated 28 million Americans without any health insurance, according to the Census Bureau. <a href="https://www.census.gov/content/dam/Census/library/visualizations/2021/demo/p60-274/figureB1.pdf">In 2013, only 86.7%</a> of the country was insured.</p>
<p>Our state, <a href="https://www.healthinsurance.org/medicaid/missouri">Missouri, expanded Medicaid on Oct. 1, 2021</a>. The state estimates that as <a href="https://missouriindependent.com/2021/01/27/gov-parsons-budget-funds-missouri-medicaid-expansion-without-cuts-to-other-needs/">many as 275,000</a> people are newly eligible, though only about <a href="https://dss.mo.gov/mis/clcounter/">64,000 enrolled in the first five months</a>. Oklahoma expanded Medicaid in July 2021, enrolling more than <a href="https://oklahoma.gov/ohca/about/newsroom/2021/november/more-than-200000-oklahomans-enrolled-in-soonercare-through-medicaid-expansion.html">200,000</a> in its first few months. <a href="https://sdsos.gov/elections-voting/assets/2022ConstitutionalAmendmentDPressRelease.pdf">South Dakota</a> may be next: its voters will decide whether to expand Medicaid in November 2022.</p>
<p>Of the 28.6 million Americans who have enrolled in Medicaid or CHIP since the ACA was rolled out, about 60% obtained coverage <a href="https://www.kff.org/health-reform/state-indicator/total-monthly-medicaid-and-chip-enrollment/">prior to the COVID-19 pandemic</a>. </p>
<h2>Response to the COVID-19 pandemic</h2>
<p>In March 2020, the federal government responded to what it correctly anticipated as the sharp growth of Medicaid and CHIP coverage.</p>
<p>At the time, an <a href="https://www.bls.gov/opub/mlr/2021/article/unemployment-rises-in-2020-as-the-country-battles-the-covid-19-pandemic.htm">unemployment surge</a> was stripping millions of workers of their economic stability, including health insurance coverage. Medicaid enrollments tend to rise during bad economic times, as people become eligible due to lower incomes. The pandemic was no different, particularly in 2020.</p>
<p>What’s different this time is that states, which administer Medicaid and CHIP, haven’t been allowed to kick anyone out of the program during this period – even if they would have lost eligibility due to higher earnings.</p>
<p>This restriction will continue as long as the federal government public health emergency declaration remains in effect. To help states with that increased financial burden, the <a href="https://www.kff.org/coronavirus-covid-19/issue-brief/how-much-fiscal-relief-can-states-expect-from-the-temporary-increase-in-the-medicaid-fmap/">federal government increased its share</a> of Medicaid payments to states. </p>
<p>In January 2022, the Biden administration renewed the public health emergency for another three months. The emergency declaration is scheduled to expire on <a href="https://ccf.georgetown.edu/2022/01/14/secretary-becerra-extends-the-phe-what-does-this-mean-for-medicaid-and-the-continuous-enrollment-provision/">April 16</a>. </p>
<p>Soon after this measure expires, millions who have been covered by Medicaid but now make too much money to qualify <a href="https://khn.org/news/article/why-millions-on-medicaid-are-at-risk-of-losing-coverage-in-the-months-ahead/">could lose their eligibility</a>, particularly if they live in states that have not yet expanded Medicaid. </p>
<p>But it’s not clear whether the number of Americans enrolled in these programs will decline sharply. In part, that’s because more people are getting access to Medicaid for the first time due to their states’ participation in its expansion.</p>
<p>[<em>You’re smart and curious about the world. So are The Conversation’s authors and editors.</em> <a href="https://memberservices.theconversation.com/newsletters/?source=inline-youresmart">You can read us daily by subscribing to our newsletter</a>.]</p><img src="https://counter.theconversation.com/content/176424/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Heather Bednarek receives funding from the Missouri Foundation for Health. </span></em></p><p class="fine-print"><em><span>Ellen Barnidge receives funding from Missouri Foundation for Health. </span></em></p>Most states have taken advantage of the opportunity to expand access to Medicaid since 2014 through the Affordable Care Act. That’s helping reduce the number of uninsured people.Heather Bednarek, Associate Professor of Economics, Saint Louis UniversityEllen Barnidge, Associate Professor of Behavioral Science and Health Education; Interim Dean of the College for Public Health and Social Justice, Saint Louis UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1572162021-03-25T12:24:48Z2021-03-25T12:24:48ZWhat the American Rescue Plan says about President Biden’s health care priorities – and what they mean for you<figure><img src="https://images.theconversation.com/files/391310/original/file-20210324-17-piq131.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5932%2C3886&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">On the campaign trail Oct. 28, 2020, in Wilmington, Delaware, Joe Biden talks about the need to build up the Affordable Care Act.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/democratic-presidential-nominee-joe-biden-delivers-remarks-news-photo/1229328585?adppopup=true">Drew Angerer/Getty Images</a></span></figcaption></figure><p>As millions of Americans receive COVID-19 vaccines, the Affordable Care Act just got a booster shot of its own. </p>
<p>After <a href="https://www.nytimes.com/2021/03/22/us/politics/biden-obamacare-anniversary.html">11 years</a> of existential threat and months after an <a href="https://www.npr.org/2020/11/10/933462515/supreme-court-appears-likely-to-uphold-obamacare">argument before the Supreme Court</a>, the ACA has been strengthened under President Joe Biden’s American Rescue Plan, the US$1.9 trillion economic relief package. This means greater access to health insurance at lower costs for millions of Americans.</p>
<p>The ARP is the most noteworthy expansion of health insurance benefits since the passage of the landmark legislation in 2010. Specifically, it <a href="https://www.nytimes.com/2021/02/27/upshot/biden-health-plan-obamacare.html">contains</a> an <a href="https://www.hhs.gov/about/news/2021/03/12/fact-sheet-american-rescue-plan-reduces-health-care-costs-expands-access-insurance-coverage.html">important extension of financial assistance</a> to Americans who purchase health insurance on the ACA’s private insurance exchanges.</p>
<p>As a <a href="https://law.utk.edu/directory/zack-buck/">health law professor</a> who <a href="https://papers.ssrn.com/sol3/cf_dev/AbsByAuth.cfm?per_id=1713816">focuses on health care finance and delivery</a>, I see this as a key moment to gain insight into President Biden’s preferred policy choices as he seeks to improve health care access and financing in the United States.</p>
<h2>The original policy architecture</h2>
<p>In addition to outlawing preexisting condition discrimination, providing the funding to expand Medicaid programs across the country, and encouraging Medicare spending reforms, the ACA constructed private marketplaces, known as <a href="https://www.healthcare.gov">exchanges</a>. People who did not receive health insurance from their jobs, or who were not part of Medicare, Medicaid, or any other public plan, could purchase highly regulated health insurance plans with the help of federal tax subsidies known as <a href="https://www.irs.gov/affordable-care-act/individuals-and-families/the-premium-tax-credit-the-basics">premium tax credits</a>. </p>
<p>These tax subsidies were vital to the reforms; without them, policymakers knew that fewer people would enroll, particularly because the exchange insurance plans were unaffordable for many Americans.</p>
<p>As designed, these tax credits were available to Americans making between 100% and 400% of the <a href="https://aspe.hhs.gov/poverty-guidelines">federal poverty level</a>. In 2021, the <a href="https://aspe.hhs.gov/poverty-guidelines">poverty level</a> for an individual is just under $13,000 of annual income; for a family of four, it is $26,500.</p>
<p>For many of these Americans who qualified for tax subsidy assistance to purchase health insurance, this financial assistance was indispensable. The subsidies are robust: <a href="https://www.healthinsurance.org/obamacare/subsidy-calculator/">About 85%</a> of Americans have qualified for a subsidy on the exchange, and, of those, the average subsidy pays for <a href="https://www.healthinsurance.org/obamacare/subsidy-calculator/">about 85%</a> of the overall health insurance premium for the beneficiary.</p>
<p>In 2020, the average premium was <a href="https://www.healthinsurance.org/obamacare/subsidy-calculator/">$576</a>, and the average subsidy was <a href="https://www.healthinsurance.org/obamacare/subsidy-calculator/">$492</a>, meaning that the average beneficiary paid $84 in monthly premiums.</p>
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<img alt="Protesters carrying signs that call for Medicaid expansion." src="https://images.theconversation.com/files/391458/original/file-20210324-13-17spmp0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/391458/original/file-20210324-13-17spmp0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/391458/original/file-20210324-13-17spmp0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/391458/original/file-20210324-13-17spmp0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/391458/original/file-20210324-13-17spmp0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/391458/original/file-20210324-13-17spmp0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/391458/original/file-20210324-13-17spmp0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Protesters in Miami urge state officials to expand Florida’s Medicaid program.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/deborah-dion-and-other-protesters-gather-in-the-office-of-news-photo/181320209?adppopup=true">Joe Readie/Getty Images</a></span>
</figcaption>
</figure>
<h2>An unexpected problem</h2>
<p>While the subsidy was quite generous for these income groups, many Americans with incomes just above or just below the cutoffs faced unaffordable premiums. Without federal help, individuals could face thousands of dollars in health insurance premiums per year.</p>
<p>One of the ACA’s main thrusts was to protect the poorest Americans, or those making less than 100% of the poverty level. As the law was written, this would happen through an expansion of Medicaid, the federal-state program that provides health care coverage to the poor. </p>
<p>The law contemplated that many would qualify for newly expanded Medicaid; these individuals would not need access to the new private insurance exchange. Of course, this was altered when the Supreme Court in 2012 ruled that the Medicaid expansion contemplated by the ACA <a href="https://www.kff.org/health-reform/issue-brief/a-guide-to-the-supreme-courts-decision/">could not be mandatory</a>.</p>
<p>Following the 2012 decision, most states expanded their programs, but <a href="https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/">12 states</a> have continued to refuse to expand their Medicaid programs, mainly because of concerns about costs. As a result, those under the federal poverty level living in those states that have not expanded Medicaid have fallen into a <a href="https://www.kff.org/medicaid/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/">coverage gap</a>. They have been unable to access Medicaid coverage in their states and unable to access tax credits to purchase subsidy-assisted exchange plans. </p>
<p>At the other end of the income spectrum, people making more than 400% of the poverty level faced increasing premiums. This was a particular problem for many Americans nearing age 65, especially those who were independent contractors, business owners or early retirees. And as insurance premiums increased, these Americans could <a href="https://khn.org/news/overlooked-by-aca-many-people-paying-full-price-for-insurance-getting-slammed/">not depend on any subsidy cushion to assist</a>, requiring either the purchase of extremely expensive health plans or the decision to go without health insurance.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/ldkQAbz31KY?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">President Joe Biden announces extension for enrolling for insurance through the ACA.</span></figcaption>
</figure>
<h2>The new rules</h2>
<p>But the ARP broadens subsidies for every income group. Almost everyone is now eligible for credits that limit their health insurance premiums to no more than 8.5% of their household income. </p>
<p>Specifically, according to the <a href="https://www.cbo.gov/system/files/2021-02/hwaysandmeansreconciliation.pdf">Congressional Budget Office</a>, people with incomes just over 400 percent of the poverty level “who are older or enrolled in family policies or in insurance rating areas with especially high premiums would experience the greatest reduction in net premiums.” </p>
<p>Additionally, for those lower on the income scale, the new tax credit structure grows to relieve the burden of any premium for individuals making between 100% and 150% of the poverty level (<a href="https://www.cbo.gov/system/files/2021-02/hwaysandmeansreconciliation.pdf">this reduces the premiums from the limit of 2.07% to 4.14% currently</a>). </p>
<p>These changes should make plans much more affordable for many exchange customers, better facilitating their ability to acquire health insurance. Already, <a href="https://www.nytimes.com/2021/03/22/us/politics/biden-obamacare-anniversary.html">more than 200,000 additional Americans</a> have signed up for plans during the current special enrollment period. And President Biden announced on March 23 that <a href="https://www.wsj.com/articles/biden-administration-extends-enrollment-period-for-affordable-care-act-11616533263">the enrollment period will be extended until Aug. 15</a>.</p>
<p>To address the coverage gap in holdout states, the ARP bolsters funding in an attempt to sweeten the deal for Medicaid expansion. This has <a href="https://nymag.com/intelligencer/2021/03/stimulus-spurs-new-push-for-red-state-medicaid-expansion.html">led to renewed consideration</a> and <a href="https://www.usnews.com/news/best-states/wyoming/articles/2021-03-24/wyoming-house-passes-medicaid-expansion-bill-on-32-28-vote">garnered additional support</a> for Medicaid expansion in these states.</p>
<figure class="align-center ">
<img alt="A woman wearing a hat that says " src="https://images.theconversation.com/files/391455/original/file-20210324-15-c2jwdl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/391455/original/file-20210324-15-c2jwdl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/391455/original/file-20210324-15-c2jwdl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/391455/original/file-20210324-15-c2jwdl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/391455/original/file-20210324-15-c2jwdl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/391455/original/file-20210324-15-c2jwdl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/391455/original/file-20210324-15-c2jwdl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Debate has swirled for years over whether the U.S. should switch to a single-payer system.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/healthcare-reform-activist-wears-a-hat-as-she-protests-news-photo/88051954?adppopup=true">Justin Sullivan/Getty Images</a></span>
</figcaption>
</figure>
<h2>The policy choice</h2>
<p>In addition to providing tangible benefits to those buying health insurance on the private health insurance exchange, the move by President Biden illustrates his commitment to bolstering the ACA. Indeed, for his first big move on health policy, Biden is strengthening private insurance. </p>
<p>This is a far cry from the more dramatic reforms sought by some advocates, such as “<a href="https://www.nbcnews.com/politics/elections/what-medicare-all-how-would-it-work-n1014256">Medicare for All</a>” proposals, or extensions to traditional Medicare, or even more moderate but still disruptive reforms like a public option. Instead of deconstructing private insurance, Biden is making it more durable. </p>
<p>This signals a continuation of the status quo from the Obama administration, and not a dramatic shift in how the federal government conceives of health care insurance in this country. A world in which the ACA provides more financial insulation for more Americans may be a world in which dramatic cost-controlling reforms seem less likely. And while these welcomed changes will limit the health care expenditures for which many Americans are responsible, the large-scale, endemic causes of the high cost of American health care are likely to remain in place. </p>
<p>[<em>Get facts about coronavirus and the latest research.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=coronavirus-facts">Sign up for The Conversation’s newsletter.</a>]</p><img src="https://counter.theconversation.com/content/157216/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Zack Buck does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Stimulus checks received a lot of attention during debates about the stimulus package, but it may be expansion of health insurance that will have the longest-lasting effect on Americans.Zack Buck, Associate Professor of Law, University of TennesseeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1088142018-12-20T21:23:37Z2018-12-20T21:23:37ZHow wealth inequality in the US affects health inequality in the US: 4 essential reads<figure><img src="https://images.theconversation.com/files/251331/original/file-20181218-27779-1xpmye1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Even when black men attain higher education and greater social status, their health is still not as good as white men's health, a study this year found. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-portrait-young-african-american-man-258784235?src=YYiM9VMl0ObIrBcCwJ2Dcg-1-70">mimagephotography/Shutterstock.com</a></span></figcaption></figure><p><em>Editor’s note: As we come to the end of the year, Conversation editors take a look back at the stories that – for them – exemplified 2018.</em></p>
<p>If you have health insurance, a nice home and a decent job, why should you care about health inequality in the U.S.? </p>
<p>This question was the underlying theme of several articles penned by health policy scholars in The Conversation in 2018. They explained such topics such as threats to the Affordable Care Act, insurance coverage, Medicaid expansion and the lack of access to health care for many people – the so-called health care gap. These experts argued that this gap is actually a threat to the system that serves all Americans. </p>
<h2>1. A political ruling</h2>
<p>The ACA was passed in part to narrow the health care gap in the U.S., but the law constantly has been under attack. The most recent attempt to gut the law occurred on Dec. 14, 2018, when a Texas judge deemed the law unconstitutional. West Virginia University health policy scholars Simon Haeder and Valarie Blake <a href="https://theconversation.com/why-the-texas-ruling-on-obamacare-is-on-shaky-legal-ground-108884">analyzed the ruling</a> and unpacked some of the potential consequences if the law were overturned. </p>
<blockquote>
<p>“Gone would be provisions that combat fraud and abuse in Medicaid and Medicare.</p>
<p>"Gone would be provisions <a href="https://www.npr.org/sections/health-shots/2017/01/24/510668899/obamacare-repeal-threatens-a-health-benefit-popular-in-coal-country">for coal miners suffering from black lung and their survivors</a>.</p>
<p>"Gone would be efforts to improve provider quality, medical innovation, and data collection efforts to reduce health disparities. </p>
<p>"The list keeps going,”
they wrote.</p>
</blockquote>
<h2>2. The costs of delayed care</h2>
<p>While estimates vary, studies that have looked at health gaps have suggested that as much as <a href="https://jointcenter.org/sites/default/files/Economic%20Burden%20of%20Health%20Inequalities%20Fact%20Sheet.pdf">30 percent of direct medical costs</a> for African-Americans, Hispanics or Asian-Americans were excess costs because of health care disparities. </p>
<p>Some of these differences start at birth, or even before. As Jessica Young, an assistant professor at American University, <a href="https://theconversation.com/being-born-in-the-wrong-zip-code-can-shorten-your-life-104037">found in a study</a> of health outcomes in various ZIP codes, where a person lives makes a great deal of difference in his or her health.</p>
<blockquote>
<p>“My unpublished results show that infants are about 20 percent more likely to die before their first birthday in distressed counties. Adults in distressed counties are 18 percent more likely to report poor or fair health than those in prosperous counties,” she wrote.</p>
</blockquote>
<h2>3. Black women are more likely to die from breast cancer</h2>
<p>The gaps in health outcomes are particularly apparent between African-American women and white women who have breast cancer. African-American women are <a href="https://theconversation.com/why-is-breast-cancer-mortality-higher-for-african-american-women-than-for-white-women-91381">more likely to die from the disease</a> than white women, wrote Padmashree Rida and Ritu Aneja from Georgia State University. And while biology plays a role, access to care also is a significant factor, the researchers wrote:</p>
<blockquote>
<p>“In the U.S., about 23.1 percent of black women live in poverty, compared to 9.6 percent of white women. Studies have shown that a lack of resources makes a huge difference in survival rates, treatment responses, and progression of disease. Poor women are less likely to have good quality health insurance, to get as much information on early detection and screening, and to have access to the best health care and latest treatments.”</p>
</blockquote>
<h2>4. Not an easy fix</h2>
<p>These health gaps are not easy to close, in part because of broader societal reasons, scholars wrote. For example, African-Americans do not derive benefit from the same advances, such as higher educational attainment and better jobs, that help whites achieve upward mobility and better health. <a href="https://theconversation.com/why-its-hard-for-blacks-to-pull-themselves-up-by-bootstraps-when-it-comes-to-health-92717">Shervin Assari</a> from the University of Michigan wrote this:</p>
<blockquote>
<p>“Although indicators of individualism are beneficial to the health and well-being of whites, according to several studies by my team, these indicators fail to protect blacks. Ironically, a high sense of desire to take control over their lives puts blacks at an increased risk for mortality. So, it appears that, due to systemic, persistent injustice and pervasive inequalities, the health gain from being able to pull oneself up by the bootstraps is considerably smaller for blacks compared to whites.”</p>
</blockquote><img src="https://counter.theconversation.com/content/108814/count.gif" alt="The Conversation" width="1" height="1" />
If a person in the US has lots of money, he or she has access to some of the best health care in the world. The story is very different for poor people and minorities.Lynne Anderson, Senior Health + Medicine Editor, The Conversation, USLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1065742018-11-07T22:06:35Z2018-11-07T22:06:35ZThe votes have been counted, the results are (mostly) in: What’s next for health care?<figure><img src="https://images.theconversation.com/files/244429/original/file-20181107-74763-effznu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Sen. Joe Manchin, a Democrat, was re-elected in West Virginia, where voters cited health care as a major concern.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Election-2018-Senate-Manchin-West-Virginia/70e0425d9c7e42c6a2b47ebbc3580e32/6/0">Tyler Evert/AP Photo</a></span></figcaption></figure><p>Ever since the <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1541-0072.2012.00446.x">legislative battle over the passage of the Affordable Care Act</a>, health care has dominated the political landscape in the United States. First, <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1541-0072.2012.00446.x">the bruising fight to enact the Affordable Care Act</a>. It was followed by the equally <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/puar.12065">bruising battle over its implementation</a>, which has <a href="https://read.dukeupress.edu/jhppl/article-abstract/43/2/271/133583">lingered on</a>. </p>
<p>Early on, it brought with it <a href="https://read.dukeupress.edu/jhppl/article-abstract/40/2/281/13726">dramatic electoral losses by Democrats at both the federal and state levels</a>, which handed Republicans control of both chambers of Congress as well as many governorships and state legislatures. </p>
<p>Yet after <a href="https://theconversation.com/republicans-attacking-obamacare-one-more-time-92568">two years of full-on assaults on the health law</a> under unified Republican control in Washington, D.C., health care was once more a <a href="https://khn.org/news/midterm-results-show-health-is-important-to-voters-but-no-magic-bullet/">dominant issue for most voters</a>. This time around, health care appears to have helped Democrats with significant increases in the <a href="https://khn.org/news/midterm-results-show-health-is-important-to-voters-but-no-magic-bullet/">House of Representatives as well as many state races</a>. As Republicans expand their majority in the Senate and with President Donald Trump in the White House, how will the midterm election results change anything going forward?</p>
<h2>The big winner: Medicaid (and Medicare)</h2>
<p>In a night with mixed results, <a href="https://theconversation.com/not-just-for-the-poor-the-crucial-role-of-medicaid-in-americas-health-care-system-78582">Medicaid</a> came out a winner in a number of ways. For one, without control of the House of Representatives, efforts to <a href="https://theconversation.com/how-the-tax-bill-opens-wide-a-big-back-door-to-overhaul-health-care-88624">undo the expansion under the Affordable Care Act</a>, <a href="https://theconversation.com/how-the-latest-effort-to-repeal-obamacare-would-affect-millions-84317">capping spending on the program by block granting it</a>, or <a href="https://www.dropbox.com/s/7ogsghmra0tdjbz/Haeder%20WV%20Medicaid%20Work%20Requirements%20Public.pdf?dl=1">implementing a statutory provision for work requirements</a> are off the table.</p>
<p>At the state level, changes are also profound. In three red states, <a href="https://www.npr.org/sections/health-shots/2018/11/07/664661676/a-winning-idea-medicaid-expansion-prevails-in-idaho-nebraska-and-utah">Utah, Nebraska and Idaho</a>, voters told their legislators to expand the program, potentially adding insurance coverage to more than 300,000. Moreover, Democratic gubernatorial wins in <a href="https://www.nytimes.com/interactive/2018/11/06/us/elections/results-governor-elections.html">Wisconsin, Kansas and Maine</a> could move those states toward expansion.</p>
<p>Yet, Medicaid could have done even better. A ballot initiative to fund the state’s Medicaid expansion via tobacco taxes failed in <a href="https://www.healthleadersmedia.com/strategy/3-red-states-approve-medicaid-expansion-montana-votes-no">Montana under heavy assault by tobacco companies</a>. If the legislature does not provide continued funding, Montana may be the first state to undo the Medicaid expansion. <a href="https://www.nytimes.com/interactive/2018/11/06/us/elections/results-governor-elections.html">Republican wins in Alaska</a> could also undo the expansion there. </p>
<p>Moreover, initiatives in Nebraska and Idaho did not include a funding mechanism, which may delay expansion there. Perhaps most crucially, millions more could have moved closer to insurance coverage with Democratic wins in <a href="https://www.nytimes.com/interactive/2018/11/06/us/elections/results-governor-elections.html">Georgia and Florida</a>.</p>
<p>The elections also brought mixed prospects for the future of <a href="https://www.dropbox.com/s/7ogsghmra0tdjbz/Haeder%20WV%20Medicaid%20Work%20Requirements%20Public.pdf?dl=1">work requirements for Medicaid beneficiaries</a>. Newly elected Democratic governors in states like <a href="https://www.nytimes.com/interactive/2018/11/06/us/elections/results-governor-elections.html">Wisconsin, Kansas and Michigan</a> may seek to weaken or undo them, while newly elected <a href="https://www.nytimes.com/interactive/2018/11/06/us/elections/results-governor-elections.html">Republican governors in Ohio and Florida</a> may seek to strengthen and expand them. </p>
<p>Finally, <a href="https://www.nytimes.com/interactive/2018/11/06/us/elections/results-house-elections.html">loss of the House of Representatives</a> also means that Republicans will be stymied in their attempts to <a href="https://www.forbes.com/sites/teresaghilarducci/2018/11/02/republican-public-opposition-to-social-security-and-medicare/">curtail and privatize Medicare</a>, the insurance program for America’s seniors.</p>
<h2>Close second: Medical marijuana</h2>
<p>Despite continued federal opposition, the country seems to move decisively towards the legalization of marijuana. For one, while a measure was defeated in <a href="https://www.forbes.com/sites/tomangell/2018/11/06/north-dakota-marijuana-legalization-measure-fails/">North Dakota</a>, <a href="https://www.rollingstone.com/culture/culture-news/cannabis-pot-michigan-utah-missouri-weed-752669/">Michigan</a> followed its neighbor to the north and became the 10th U.S. state to allow recreational marijuana use. Two other states, <a href="https://www.myrtlebeachonline.com/news/article221269765.html">Missouri</a> and <a href="https://www.forbes.com/sites/tomangell/2018/11/07/utah-voters-approve-medical-marijuana/">Utah</a>, moved to become the 31st and 32nd states to allow medical marijuana. Giving the <a href="http://www.spokesman.com/stories/2018/nov/04/cannabis-can-help-combat-opioid-epidemic-studies-s/">growing evidence that marijuana may help counter the devastating opioid epidemic</a>, these developments may prove quite positive from a health care perspective.</p>
<h2>Too early to tell: The Affordable Care Act</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/244434/original/file-20181107-74778-10j2xz5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/244434/original/file-20181107-74778-10j2xz5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/244434/original/file-20181107-74778-10j2xz5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/244434/original/file-20181107-74778-10j2xz5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/244434/original/file-20181107-74778-10j2xz5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/244434/original/file-20181107-74778-10j2xz5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/244434/original/file-20181107-74778-10j2xz5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The Affordable Care Act is likely safe, for two years anyway, after Democrats gained control of the House of Representatives Nov. 6, 2018.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/caldwell-idahousa-december-6-view-healthcare-166155479?src=XljaEiHYyJiYBiAt8FBoZQ-1-2">txking/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>As with Medicaid, the <a href="https://www.nytimes.com/interactive/2018/11/06/us/elections/results-house-elections.html">Democratic takeover of the House</a> brings some relief for the <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/puar.12065">Affordable Care Act</a>. The effects on the Medicaid expansion have been discussed above, but more generally, Democrats in Congress can now hold up any major statutory effort to undo or undermine the Affordable Care Act. </p>
<p>Yet despite Democratic gains across the nations, three major factors that could substantively affect the Affordable Care Act remain largely out of their control. </p>
<p>For one, with a Republican in the White House and in control of the executive branch, <a href="https://www.cambridge.org/core/journals/american-political-science-review/article/influence-and-the-administrative-process-lobbying-the-us-presidents-office-of-management-and-budget/638F34BC73235AB4833C852B24C431AF">regulatory powers</a>, such as the implementation of statutory decisions, remain staunchly in Republican hands. While largely out of the public’s eye, <a href="https://academic.oup.com/jpart/article-abstract/28/4/475/5056341">regulatory decisions account for the vast majority of lawmaking today, with broad implications</a>. The future of the Affordable Care Act as well as Medicaid will continue to be impacted by this, as exemplified by the recent decision by the Trump administration on <a href="https://theconversation.com/short-term-health-plans-a-junk-solution-to-a-real-problem-101447">short-term, limited duration and association health plans</a>.</p>
<p>Second, <a href="https://www.nytimes.com/interactive/2018/11/06/us/elections/results-senate-elections.html">Republican control of the Senate expanded</a>, and health care <a href="https://theconversation.com/born-in-the-usa-having-a-baby-is-costly-and-confusing-even-for-a-health-policy-expert-99719">moderates Susan Collins and Lisa Murkowski are no longer pivotal to many Republican efforts</a>. This is particularly important for judicial confirmations as judges across the ideological spectrum continue to shape policymaking on important decisions.</p>
<p>Finally, the future of the Affordable Care Act itself hangs in the balance as it is under threat by a <a href="https://theconversation.com/republicans-attacking-obamacare-one-more-time-92568">lawsuit sitting before a federal judge in Texas</a>. At stake are particularly protections for <a href="https://www.sciencedirect.com/science/article/pii/S0168851014002607">pre-existing conditions</a>, but the judge may declare the law in its entirety unconstitutional. This would likely lead to a protracted legal struggle all the way to the Supreme Court, with uncertain outcomes.</p>
<h2>The big loser: Americans in deep red states</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/244430/original/file-20181107-74772-r8y1ku.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/244430/original/file-20181107-74772-r8y1ku.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=409&fit=crop&dpr=1 600w, https://images.theconversation.com/files/244430/original/file-20181107-74772-r8y1ku.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=409&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/244430/original/file-20181107-74772-r8y1ku.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=409&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/244430/original/file-20181107-74772-r8y1ku.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=514&fit=crop&dpr=1 754w, https://images.theconversation.com/files/244430/original/file-20181107-74772-r8y1ku.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=514&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/244430/original/file-20181107-74772-r8y1ku.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=514&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Andrew Gillum, right, shakes hands with his running mate Chris King after conceding his loss for Florida governor to Ron DeSantis. Gillum had pledged to expand Medicaid if elected.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Election-2018-Governor-Gillum-Florida/7ba109bb5a03400f9b3d3b9f69854364/3/0">Chris O'Meara/AP Photo</a></span>
</figcaption>
</figure>
<p>The midterm election results continued the nation’s path toward a country where one’s place of residence has tremendous implications for one’s ability to access <a href="https://www.cambridge.org/core/journals/journal-of-policy-history/article/inching-toward-universal-coverage-statefederal-healthcare-programs-in-historical-perspective/E94A03DD1F60F9DCBE3DDE9728DA3224">crucial social services and health care, with significant implications for socio-economic and health outcomes</a>. </p>
<p>In places like California, Oregon and New York, Democratic legislatures and governors will likely move full speed ahead in expanding access to coverage and care by protecting the Affordable Care Act and by designing and implementing creative approaches to solving important health care issues. However, they will face impediments in their quest by an unsupportive executive branch in Washington, D.C., which will limit their ability to be fully successful.</p>
<p>Yet in other places, states will take the opposite path. States like Texas, Oklahoma, Florida and Georgia will likely continue their fight against support programs like Medicaid by <a href="https://www.dropbox.com/s/7ogsghmra0tdjbz/Haeder%20WV%20Medicaid%20Work%20Requirements%20Public.pdf?dl=1">adding administrative burdens including premiums, frequent recertification and work requirements</a>. Ironically, in red states with popular initiatives and referendums <a href="https://www.npr.org/sections/health-shots/2018/11/07/664661676/a-winning-idea-medicaid-expansion-prevails-in-idaho-nebraska-and-utah">voters themselves have counteracted some of these acts by their legislatures by, for example, expanding Medicaid</a>. Yet, most states that have yet to expand Medicaid do not allow for popular votes on the issue. </p>
<p>Overall, these developments will further widen the chasm between states in a country facing a deep and lasting partisan divide. In some places, support programs like Medicaid and Supplemental Nutrition Assistance Program (SNAP) will help those in poverty lead healthier and more productive lives, while those in others places will lack such support. </p>
<p>Perhaps most importantly, these experiences will shape individuals’ perceptions of themselves, their country and <a href="http://www.cornellpress.cornell.edu/book/?GCOI=80140100344210">democracy, with significant implications on efficacy and involvement in the political process</a>.</p>
<h2>The takeaways for 2020</h2>
<p>In my opinion, health care will continue to play a dominant role going into the 2020 election cycle. For one, it accounts for <a href="https://theconversation.com/us-health-care-system-a-patchwork-that-no-one-likes-85252">a fifth of our economy and holds tremendous implications for personal and governmental budgets</a>. With that much at stake, political conflict is inevitable.</p>
<p>Moreover, health care has traditionally been a <a href="https://www.cambridge.org/core/journals/journal-of-policy-history/article/inching-toward-universal-coverage-statefederal-healthcare-programs-in-historical-perspective/E94A03DD1F60F9DCBE3DDE9728DA3224">highly ideologically driven</a> issue in American politics. With moderate Republicans losing their races, the remaining GOP members of Congress will be more conservative. They will also likely be fully supportive of their president. Both parties have much to gain from digging in on their positions, leaving the rest of American to pay the tab. <a href="https://theconversation.com/us-health-care-system-a-patchwork-that-no-one-likes-85252">Bipartisan compromise may prove elusive</a>.</p>
<p>Finally, crucial and controversial decisions remain ahead for health care, including <a href="https://theconversation.com/republicans-attacking-obamacare-one-more-time-92568">litigation about the Affordable Care Act</a>, <a href="https://www.dropbox.com/s/7ogsghmra0tdjbz/Haeder%20WV%20Medicaid%20Work%20Requirements%20Public.pdf?dl=1">work requirements for Medicaid beneficiaries</a>, the future of Medicare, and reining in medical and pharmaceutical costs. Unquestionably, these far-reaching controversies will keep health care front and center.</p><img src="https://counter.theconversation.com/content/106574/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon is a Fellow in the Interdisciplinary Research Leaders Program, a national leadership development program supported by the Robert Wood Johnson Foundation to equip teams of researchers and community partners in applying research to solve real community problems.</span></em></p>Voters listed health care as one of their biggest concerns in the midterm elections. Were their concerns addressed? The results are mixed.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/843172017-09-20T03:14:08Z2017-09-20T03:14:08ZHow the latest effort to repeal Obamacare would affect millions<figure><img src="https://images.theconversation.com/files/186610/original/file-20170919-16985-113283u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">From left, Sen. Dean Heller, R-Nev., Sen. Bill Cassidy, R-La., Sen. Ron Johnson, R-Wis., and Sen. Lindsey Graham, R-S.C., hold a press conference on Capitol Hill in Washington, Wednesday, Sept. 13, 2017. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Congress-Health-Overhaul/62e533c109554ce28adbfb4e275e46a6/1/0">AP Photo/Andrew Harnik</a></span></figcaption></figure><p>At the end of July, the nation held its collective breath as Senate Majority Leader Mitch McConnell (R-Ky.) looked poised to achieve his most formidable parliamentary accomplishment: the <a href="https://www.nytimes.com/2017/07/27/us/politics/senate-health-care-vote.html?mcubz=0&_r=0">repeal and replacement of the Affordable Care Act</a>.</p>
<p>But Republican hopes were dashed by one of their own, Sen. John McCain (R-Ariz.), who <a href="https://www.washingtonpost.com/powerpost/the-night-john-mccain-killed-the-gops-health-care-fight/2017/07/28/f5acce58-7361-11e7-8f39-eeb7d3a2d304_story.html?utm_term=.00c807d2ce92">cast the deciding vote</a> that appeared to decisively derail the multi-year effort. </p>
<p>McCain called to return to “regular order,” to work through committees, to bring in and listen to experts, to be open and transparent, and perhaps most importantly, to at least listen to both parties.</p>
<p>And indeed, Senators Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) went to work, bringing together demands from Republicans like <a href="https://www.axios.com/murray-makes-big-concession-in-bipartisan-health-talks-2486922713.html">more flexibility for states to waive certain provisions of the ACA</a>, and demands from Democrats to provide cost-sharing subsidies, for example, to <a href="http://thehill.com/policy/healthcare/350643-senate-health-panel-aims-for-deal-on-stabilizing-markets-early-next-week">stabilize health care markets</a>. The bipartisanship appeared to be spreading as <a href="https://www.hatch.senate.gov/public/index.cfm/releases?ID=071428C9-0FD3-4C76-B3E1-734F93B46CF4">Orrin Hatch (R-Utah) and Ron Wyden (D-Ore.)</a> appeared to have reached an agreement on the future of the Children’s Health Insurance Program.</p>
<p>Now Republican hopes of repealing the ACA have been rekindled with the <a href="http://files.kff.org/attachment/Summary-of-Graham-Cassidy-Heller-Johnson-Amendment">Graham-Cassidy-Heller-Johnson Amendment</a> led by Senators Lindsey Graham (R-S.C.) and Bill Cassidy (R-La). </p>
<p>Like all health care legislation, the bill is complex, but the broad outlines of it are rather clear: It would undo much of the reforms implemented through the ACA and then go a step further.</p>
<h2>What’s in the bill?</h2>
<p>Senate Republicans are rushed once more as they want to achieve health care reform by September 30, the deadline to pass the bill through the <a href="http://www.politifact.com/truth-o-meter/article/2017/jun/22/senate-health-care-bills-two-front-war-policy-and-/">reconciliation process</a> which requires only a simple majority. Indeed, due to their haste, the Congressional Budget Office <a href="https://www.cbo.gov/publication/53116">will not be able to provide any estimates of the bill’s effects on the deficit, health insurance coverage or premiums</a>.</p>
<p>Graham-Cassidy seeks to undo many of the reforms initiated by the ACA. For one, by 2020 it would eliminate the ACA’s Medicaid expansion, which has provided coverage <a href="http://www.kff.org/health-reform/state-indicator/medicaid-expansion-enrollment/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">for 12 million Americans</a> for <a href="http://jhppl.dukejournals.org/content/40/2/281.short">states that chose to expand their program</a>. However, it would prevent new states from expanding their program by 2017. It would also eliminate the insurance marketplace subsidies to assist individuals purchase coverage and with out-of-pocket costs. </p>
<p>To soften states’ financial losses, Graham-Cassidy partially replaces funding for both components with a temporary block grant to states that would run out in 2026. Yet even with the block grant, states would see their funding reduced by a combined <a href="https://www.cbpp.org/research/health/cassidy-graham-plans-damaging-cuts-to-health-care-funding-would-grow-dramatically-in">US$239 billion over six years</a>, according to an analysis by the left-leaning Center on Budget and Policy Priorities. </p>
<p>Graham-Cassidy also significantly alters the regulatory reforms implemented via the ACA. The much-maligned individual and employer mandates would be repealed retroactively. The individual mandate requires that all people of a certain income buy insurance or face a penalty. The employer mandate requires that all employers of a certain size provide insurance to their employees.</p>
<p>While individuals still could not be turned down based on their health status, states could also obtain waivers to weaken or wholly eliminate <a href="https://theconversation.com/how-pre-existing-conditions-became-front-and-center-in-health-care-vote-77138">preexisting condition protections</a>. For example, the Center for American Progress has estimated that individuals could face insurer premium <a href="https://www.americanprogress.org/issues/healthcare/news/2017/09/18/439091/graham-cassidy-aca-repeal-bill-cause-huge-premium-increases-people-pre-existing-conditions/">surcharges of $140,000 for metastatic cancer, $17,000 for being pregnant and $26,000 for rheumatoid arthritis</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/186642/original/file-20170919-22701-b07sdf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/186642/original/file-20170919-22701-b07sdf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=317&fit=crop&dpr=1 600w, https://images.theconversation.com/files/186642/original/file-20170919-22701-b07sdf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=317&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/186642/original/file-20170919-22701-b07sdf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=317&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/186642/original/file-20170919-22701-b07sdf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=398&fit=crop&dpr=1 754w, https://images.theconversation.com/files/186642/original/file-20170919-22701-b07sdf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=398&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/186642/original/file-20170919-22701-b07sdf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=398&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In one analysis, states could choose to not cover well visits to doctors.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/senior-doctor-patient-giving-prescription-medication-334498577?src=ywBZ1LFStjWJgkk4IwaquA-1-26">rocketclips/www.shutterstock.com</a></span>
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</figure>
<p>Similarly, states would be able to waive the ACA’s <a href="https://theconversation.com/essential-health-benefits-suddenly-at-center-of-health-care-debate-but-what-are-they-75125">Essential Health Benefit</a> provisions that required insurers to cover cost for expenditures like ambulance transport, prescription drugs and inpatient services. This would affect all individuals in the respective states because lifetime and annual limits apply only to the Essential Health Benefits. States could also waive the requirement to cover preventive services like immunizations and well-child visits.</p>
<p>Yet like most of the previous efforts to repeal the ACA over the past several months, Graham-Cassidy goes well beyond addressing changes brought about by the ACA. Most severely, the bill moves to dramatically slash and transform the Medicaid program. It would do so by establishing severe per capita caps: that is, it would provide a set amount of money for each enrolled individual compared to an open-ended federal match. These caps, which would affect children, seniors and individuals with disabilities, would also begin in 2020. They would be adjusted by inflation, but not the much larger medical inflation. They would thus result in further reductions over time. The resulting cuts would amount to $175 billion by 2026. </p>
<p>It would also allow states to establish work requirements for the program, defund Planned Parenthood and further expand <a href="https://theconversation.com/why-health-savings-accounts-are-a-bust-for-the-poor-but-a-boost-for-the-privileged-81013">Health Savings Accounts</a>, among other things.</p>
<p>However, unlike most of its <a href="http://files.kff.org/attachment/Summary-of-the-Better-Care-Reconciliation-Act-Updated-072017">predecessors</a>, Graham-Cassidy provides political protections for its supporters because the full extent and severity of its cuts would not fully emerge until 2027, at least two elections away for most senators. The Center on Budget and Policy Priorities has estimated that the effect in 2027 alone, the cliff year, would amount to <a href="https://www.cbpp.org/research/health/cassidy-graham-plans-damaging-cuts-to-health-care-funding-would-grow-dramatically-in">$300 billion</a>. California alone would lose $58 billion, while the state of West Virginia would lose $2 billion. The Center on Budget and Policy Priorities also expects that <a href="https://www.cbpp.org/research/health/cassidy-graham-plans-damaging-cuts-to-health-care-funding-would-grow-dramatically-in">more than 32 million</a> Americans would lose their insurance.</p>
<h2>A step backward … and not addressing the real issues</h2>
<p>In my reading, Graham-Cassidy, just like all its predecessors, does little to fix the problems of the American health care system.</p>
<p>Our system is generally of low quality. Medical errors kill more than <a href="http://www.bmj.com/content/353/bmj.i2139">250,000 Americans each year, making it the third leading cause of death</a>. Prescription errors alone are responsible for more than <a href="https://www.forbes.com/sites/leahbinder/2013/09/03/the-shocking-truth-about-medication-errors/#6e7c907510ab">7,000 deaths</a>. Virtually the entire developed world, and many less-developed countries, are ahead of us with regard to <a href="https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html">infant mortality</a>. The list goes on.</p>
<p>Despite these obvious shortcomings, our health care system is also, by far, the most expensive system in the world. We spend more than <a href="http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective">17 percent of our GDP, or well over $9,000 per person</a>, on health care. This compares to <a href="http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective">10 percent and $3,700 for Japan</a>, <a href="http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective">11 percent and $4,900 for Germany</a>, and <a href="http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective">9 percent and $3,300 for the United Kingdom</a>.</p>
<p>And yet, even after the coverage expansions of the Affordable Care Act, and <a href="http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective">after spending more money from the public’s purses than all but two countries</a>, our uninsurance rates just <a href="http://www.dailynews.com/2017/09/16/healthcare-uninsured-rate-in-us-falls-to-record-low-of-8-8/">inched below 10 percent, and more than 28 million Americans are without insurance</a>.</p>
<p>Indeed, we do not even cover all children in this country, although the rate of insurance from children reached a <a href="http://www.kff.org/other/state-indicator/children-0-18/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">historic high of 95 percent</a>.</p>
<p>With low quality, high costs and lack of universal coverage, much needs to be improved about the American health care system. Unfortunately, Graham-Cassidy as currently written does nothing to improve quality, and it does nothing to reduce the underlying drivers of excessive costs. Indeed, it reverses the significant progress achieved under the ACA in offering coverage to all Americans.</p>
<p>Large-scale changes to the American health care system cannot and should not be quickly patched together without input from the Congressional Budget Office, policy experts, the public and the other party. Many lives and one-sixth of our economy hang in the balance. The American public deserves better.</p><img src="https://counter.theconversation.com/content/84317/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A Senate vote in July seemed to signal the end of efforts to kill the Affordable Care Act. With a Sept. 30 deadline looming, though, a new bill has real possibilities. Here’s why that could be bad.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/799912017-07-25T01:12:50Z2017-07-25T01:12:50ZHow killing the ACA could lead to more opioid deaths in West Virginia and other Trump states<figure><img src="https://images.theconversation.com/files/179502/original/file-20170724-11666-1wuw0pn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A neighborhood in Huntington, West Virginia, where more than two dozen opioid overdoses occurred within four hours in August, 2016. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Drug-Overdoses-Four-Hours-in-Huntington/5b517c23a3e3498f9262ba9610a9ff30/33/0">AP Photo/Claire Galofino</a></span></figcaption></figure><p>President Trump spoke at the National Scout Jamboree in West Virginia on July 24, joining a long list of presidents who have spoken to the huge meeting of Boy Scouts, troop leaders and volunteers. The visit was not surprising, as West Virginia, in the center of Appalachia, is overwhelmingly Trump Country. </p>
<p>It is also at the center of the nation’s opioid epidemic, with a rate of <a href="https://www.hcp.med.harvard.edu/sites/default/files/Key%20state%20SMI-OUD%20v3.pdf">42 overdose deaths per 100,000</a>, more than double the national average. Indeed, on Aug. 15, 2016, Huntington, home of Marshall University, experienced more than two dozen overdoses in a <a href="http://www.cnn.com/2016/08/17/health/west-virginia-city-has-27-heroin-overdoses-in-4-hours/index.html">span of just four hours</a>. </p>
<p>West Virginia is also a state that has been aggressive in taking advantage of <a href="http://onlinelibrary.wiley.com/doi/10.1111/puar.12065/full">opportunities offered by the federal government under the Affordable Care Act</a>, including the ACA insurance marketplaces and the Medicaid expansion. </p>
<p>While about <a href="https://www.nytimes.com/elections/results/west-virginia">two-thirds of voters supported</a> Trump in the election, support for expanding Medicaid has largely been bipartisan. At least until now.</p>
<p>With GOP repeal-and-replace efforts still very much up in the air, one thing has become clear: All proposals made public by congressional Republicans have significant, detrimental effects on West Virginia’s and America’s ability to combat the opioid epidemic.</p>
<h2>An escalating problem</h2>
<p>The opioid addiction crisis in America is growing worse. An analysis in June 2017 by The New York Times showed a <a href="https://www.nytimes.com/interactive/2017/06/05/upshot/opioid-epidemic-drug-overdose-deaths-are-rising-faster-than-ever.html">19 percent increase in drug overdose deaths </a>from 2015 to 2016, and experts cited opioids as the likely reason for the increase.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/179507/original/file-20170724-16930-1p3t7e1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/179507/original/file-20170724-16930-1p3t7e1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/179507/original/file-20170724-16930-1p3t7e1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/179507/original/file-20170724-16930-1p3t7e1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/179507/original/file-20170724-16930-1p3t7e1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/179507/original/file-20170724-16930-1p3t7e1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/179507/original/file-20170724-16930-1p3t7e1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Opioid overdose is blamed for a sharp increase in deaths due to drug overdose. Prescription opioids used to treat pain have contributed to the epidemic.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/hydrocodone-prescription-bottle-generic-medication-name-523921741?src=_Co2MOkNI9QylEAVo8GWUA-1-4">Sherry Yates Young/Shutterstock.com</a></span>
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</figure>
<p><a href="https://www.addictioncenter.com/addiction/addiction-statistics/">More than 20 million Americans</a> suffer from an addiction. Close to <a href="https://www.addictioncenter.com/addiction/addiction-statistics/">seven million of these addicts</a> also have a mental illness. The Surgeon General’s office has estimated that the yearly losses in productivity, health care costs and criminal justice expenses for alcohol misuse and illicit drug abuse amount to <a href="https://addiction.surgeongeneral.gov/executive-summary">US$442 billion</a>. </p>
<p>In 2015, the most recent year for which figures are available from the Centers for Disease Control and Prevention (CDC), more than <a href="https://www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm">52,000 Americans died from drug overdoses</a>. More than <a href="https://www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm">33,000 of these</a> were due to opioids. This means that, compared to 1999, the number of opioid <a href="https://www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm">deaths nearly tripled</a>. </p>
<p>This epidemic is not only killing people and ripping apart families. It also has created an enormous drain on America’s health and social systems.</p>
<p>Drug overdoses lead to more than <a href="https://www.addictioncenter.com/addiction/addiction-statistics/">five million emergency department visits</a> per year.</p>
<p>In towns in West Virginia and many other states, school systems, fire and police departments, and city governments spend ever-growing funds on providing emergency <a href="http://www.emsworld.com/news/12317582/w-v-departments-footing-the-bill-for-naloxone">overdose treatments such as Naloxone</a>.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/179509/original/file-20170724-24759-10768vd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/179509/original/file-20170724-24759-10768vd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/179509/original/file-20170724-24759-10768vd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/179509/original/file-20170724-24759-10768vd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/179509/original/file-20170724-24759-10768vd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/179509/original/file-20170724-24759-10768vd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/179509/original/file-20170724-24759-10768vd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Emergency responders and departments have been taxed in dealing with opioid overdoses.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/patient-emergency-team-transfer-ambulance-blur-536327245?src=wFt5BIh2PTn5FAZfgUnBKQ-1-1">Chaikom/Shutterstock.com</a></span>
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<p>Indeed, Medicaid spending on the drug has increased by <a href="http://www.urban.org/sites/default/files/publication/91521/2001386-rapid-growth-in-medicaid-spending-on-medications-to-treat-opioid-use-disorder-and-overdose_3.pdf">90,000 percent</a> in just five years.</p>
<p>A West Virginia program to <a href="https://www.washingtonpost.com/news/wonk/wp/2017/03/07/drugs-are-killing-so-many-people-in-west-virginia-the-state-cant-keep-up-with-the-funerals/?utm_term=.f143feb25dce">support needy families with burial expenses</a> has run out of funds for five years straight.</p>
<p>The epidemic has also created tremendous problems for <a href="http://www.governing.com/topics/health-human-services/gov-opioid-epidemic-child-welfare.html">child welfare system and schools</a>, which have to deal with the drug-addicted parents and abandoned children.</p>
<p>Perhaps the saddest part of the story is the <a href="http://wvpublic.org/post/born-addicted-race-treat-ohio-valley-s-drug-affected-babies">growing number of newborns delivered by addicted mothers</a>, who have to undergo addiction treatment from the minute they are born.</p>
<h2>How Obamacare helped</h2>
<p>The ACA called for states to expand Medicaid coverage to more lower-income people. Not all states did this; the 19 who bucked expansion were Republican states.</p>
<p>But not all Republican states resisted expansion. West Virginia, desperate for help for its laid-off miners and for its thousands of people addicted to opioids, was one of <a href="http://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Current%20Status%20of%20Medicaid%20Expansion%20Decision%22,%22sort%22:%22asc%22%7D">the more than a dozen states that voted for the president and expanded Medicaid</a>.</p>
<p>The expansion of Medicaid has been crucial in two ways. For one, providing insurance coverage for an <a href="https://www.hcp.med.harvard.edu/sites/default/files/Key%20state%20SMI-OUD%20v3.pdf">additional 180,000 West Virginians</a> has proven critical to getting many of them into treatment.</p>
<p>Moreover, the expansion population was subject to the ACA’s <a href="http://www.sciencedirect.com/science/article/pii/S0168851014002607">Essential Health Benefit provisions</a>. This required states to make available substance abuse and mental health treatment to them.</p>
<p>Finally, the <a href="http://www.sciencedirect.com/science/article/pii/S0168851014002607">ACA’s Essential Health Benefit</a> provisions required policies sold in the individual market to cover addiction and mental health services. It also eliminated annual and lifetime limits on <a href="https://theconversation.com/essential-health-benefits-suddenly-at-center-of-health-care-debate-but-what-are-they-75125">these benefits</a>.</p>
<p>Overall, <a href="https://www.hcp.med.harvard.edu/sites/default/files/Key%20state%20SMI-OUD%20v3.pdf">more than 210,000 West Virginians</a> with substance abuse or mental health problems gained coverage under the ACA.</p>
<h2>Epidemic would escalate</h2>
<p>While the exact nature of Republican repeal-and-replace efforts remains unclear at this moment, all proposals made public so far would pose enormous challenges for states like West Virginia to turn the tide on the devastating opioid epidemic.</p>
<p>One of the most essential tools in fighting the epidemic, the expansion of Medicaid, would be rolled back either immediately or over several years. Furthermore, the entire Medicaid program, the <a href="https://www.theatlantic.com/politics/archive/2017/07/opioid-medicaid-health-care/533451/?utm_source=twb">backbone of states’ efforts to provide treatment and services</a> for opioid addiction treatment, would be further curtailed by per capita caps.</p>
<p>Moreover, all proposals would either outright eliminate or allow states to waive the crucial <a href="https://theconversation.com/essential-health-benefits-suddenly-at-center-of-health-care-debate-but-what-are-they-75125">Essential Health Benefit provisions</a>. These provisions require insurers to provide coverage for certain specified conditions, such as pregnancy, addiction treatment and emergency room care, that they might otherwise refuse to cover because of their costs. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/179514/original/file-20170724-16930-1meu7y8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/179514/original/file-20170724-16930-1meu7y8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/179514/original/file-20170724-16930-1meu7y8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/179514/original/file-20170724-16930-1meu7y8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/179514/original/file-20170724-16930-1meu7y8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/179514/original/file-20170724-16930-1meu7y8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/179514/original/file-20170724-16930-1meu7y8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Maternity health benefits have been considered essential care under the ACA, as has addiction treatment.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/cropped-shot-doctor-stethoscope-listening-belly-651615208?src=ST2YcfBzCleyODRQYICsjw-1-0">LIghtField Studios/Shutterstock.com</a></span>
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<p>Under certain proposals, lifetime and annual limits could also affect those covered by employer-provided insurance to lose access to crucial treatment options.</p>
<p>In its most recent iteration, Senate Republicans have added $45 billion over 10 years <a href="http://www.nbcnews.com/storyline/americas-heroin-epidemic/senate-health-care-bill-no-fix-opioid-epidemic-experts-say-n782721">specifically to deal with the opioid crisis</a> to bring on-board crucial moderates like Senators Shelley Moore Capito (Republican-West Virginia) and Robert Portman (Republican-Ohio).</p>
<p>However, as Ohio Gov. John Kasich stated, given the enormous size of the opioid problem, this amounts to “<a href="http://abcnews.go.com/Politics/senate-health-bill-force-choosing-children-seniors-disabled/story?id=48392178">spitting in the ocean</a>.” Medicaid alone spends more than <a href="http://www.urban.org/sites/default/files/publication/91521/2001386-rapid-growth-in-medicaid-spending-on-medications-to-treat-opioid-use-disorder-and-overdose_3.pdf">$1 billion annually</a> solely on medications for addiction treatments. This does not include costs to providers or treatment facilities.</p>
<h2>Moving forward</h2>
<p>Treating addiction is challenging and involves more than access to insurance coverage. However, <a href="https://www.usatoday.com/story/opinion/2017/06/22/gop-health-bill-disaster-substance-abuse-patients-vivek-murthy-column/103023032/">evidence-based treatment</a>, which includes replacement medications and counseling, has shown success in America’s fight against the epidemic ravaging many of its communities.</p>
<p>In my opinion, stemming the opioid epidemic requires a prolonged, multi-pronged approach.</p>
<p>It requires a hard look at how we prescribe painkillers. Health care providers like <a href="https://share.kaiserpermanente.org/article/kaiser-permanente-targets-reduction-of-opioid-prescribing/">Kaiser Permanente</a> have shown that success is possible.</p>
<p>It also requires taking a hard look at the <a href="https://www.bloomberg.com/view/articles/2017-07-11/states-have-good-reason-to-investigate-opioid-makers">role that pharmaceutical companies play</a>.</p>
<p>It requires providing jobs and hope to rural America, which overwhelmingly voted for President Trump and his promises, and which disproportionately suffers from this epidemic.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/179515/original/file-20170724-28519-jmsptg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/179515/original/file-20170724-28519-jmsptg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=409&fit=crop&dpr=1 600w, https://images.theconversation.com/files/179515/original/file-20170724-28519-jmsptg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=409&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/179515/original/file-20170724-28519-jmsptg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=409&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/179515/original/file-20170724-28519-jmsptg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=514&fit=crop&dpr=1 754w, https://images.theconversation.com/files/179515/original/file-20170724-28519-jmsptg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=514&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/179515/original/file-20170724-28519-jmsptg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=514&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Coal miners in Maidsville, West Virginia, ready to descend into the mines in this 1938 photo. The coal industry has been declining for a number of years, however, leading to fewer jobs in mining.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/coal-miners-ready-descend-into-mine-242289910?src=s46GMhDiHarI3hpC85iMuQ-1-1">Everett Historical/Shutterstock.com</a></span>
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<p>Most definitely, it requires also providing medical treatment to individuals trying to overcome their additions. Unfortunately, so far, none of the GOP proposals have done that. GOP proposals do not include the means to do that.</p>
<p>Trump has long championed the people of West Virginia, but a visit to the Boy Scouts does little to alleviate the suffering in the heart of Appalachia.</p><img src="https://counter.theconversation.com/content/79991/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>West Virginia favored Trump by more than 2:1 in the 2016 election, but Trump’s policies would particularly hurt the state. Its residents depend heavily on Medicaid to treat opioid addiction.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/714532017-01-18T11:03:24Z2017-01-18T11:03:24ZRural America, already hurting, could be most harmed by Trump’s promise to repeal Obamacare<figure><img src="https://images.theconversation.com/files/153124/original/image-20170117-21183-1oi0cp8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A hospital worker removing a plaque from Sac-Osage Hospital, which closed its doors in 2015.</span> <span class="attribution"><span class="source">Orlin Wagner/AP</span></span></figcaption></figure><p>The health of rural America is failing, and a repeal of the Affordable Care Act (ACA) without adequate replacement could prove disastrous. A December, 2016 report from the Centers for Disease Control and Prevention showed that for the first time in 20 years, life expectancy in the United States has <a href="https://www.cdc.gov/nchs/products/databriefs/db267.htm">declined</a>, particularly in <a href="http://www.washingtonpost.com/sf/national/2016/04/10/a-new-divide-in-american-death/?hpid=hp_no-name_whitedeath-underdisplay_1%3Ahomepage%2Fstory&tid=a_inl">small cities and rural areas, where people are dying at much higher rates</a>. This shocking trend is <a href="http://www.pnas.org/content/112/49/15078.full.pdf">driven in part by increasing mortality</a> rates for white, working-class Americans, many of whom live in rural America.</p>
<p>There is no better indicator of well-being than life expectancy, and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4802655/">reversals like this are unusual</a> for wealthy nations where successive generations increase in longevity. This has remained true for vulnerable, minority populations in America, as <a href="https://www.washingtonpost.com/news/to-your-health/wp/2016/06/03/big-gains-for-black-hispanic-longevity-in-u-s-since-2000-white-gains-much-smaller/?utm_term=.96fcf6285250">blacks and Hispanics</a> continue to make gains in life expectancy even while experiencing significant health disparities.</p>
<p>This drop in life expectancy in rural areas is linked to higher rates of chronic illness, obesity, drug overdose, alcoholism, mental illness and suicide. Death rates are most notable for rural white women, who are now much more likely than their grandmothers to <a href="http://healthaffairs.org/blog/2015/11/10/to-understand-climbing-death-rates-among-whites-look-to-women-of-childbearing-age/">suffer from obesity, smoking and alcoholism</a>. Rising rates of opioid addiction have resulted in an <a href="http://jamanetwork.com/journals/jamapediatrics/article-abstract/2592302">increase in drug dependency in newborns</a> born to rural mothers. Further, dwindling industry in these communities limits access to both employment and to health care.</p>
<p>Taken as a whole, Medicaid expansion through the ACA has resulted in <a href="http://hrms.urban.org/quicktakes/Substantial-Gains-in-Health-Insurance-Coverage-Occurring-for-Adults-in-Both-Rural-and-Urban-Areas.html">critical gains</a> toward improving rural population health by expanding insurance coverage and stabilizing rural hospitals. </p>
<p>The repeal of Medicaid expansion and collapse of the individual insurance market, which could occur as part of repeal of the ACA, could threaten strides the country has made in advancing the health of rural America.</p>
<p>As emergency medicine physicians, we treat patients across the spectrum of race, class, geography and socioeconomic status – and we know firsthand how devastating the loss of access to health care can be to vulnerable populations. We explain why repeal of the fundamental components of the ACA, commonly called Obamacare, will be uniquely disastrous for the health of rural populations.</p>
<h2>Rural health gains</h2>
<p>It is no surprise that rural Americans experienced the <a href="https://aspe.hhs.gov/sites/default/files/pdf/204986/ACARuralbrief.pdf">highest rates of coverage gains</a> through the ACA. They have been more likely to have had <a href="https://www.hrsa.gov/advisorycommittees/rural/publications/ruralimplications.pdf">inadequate access</a> to affordable health care for years. This dramatic increase in insurance is translating into improved health for these communities. </p>
<p>For example, in Arkansas and Kentucky, <a href="http://content.healthaffairs.org/content/35/1/96.abstract">Medicaid expansion resulted in fewer people</a> skipping medications due to cost, a decline in difficulty paying medical bills and an increase in regular doctor visits for chronic illnesses.</p>
<p>However, health care in rural areas under the ACA has also faced major challenges. Health care markets are now more integrated, focused on moving away from free-for-service and towards coordinated care and value-based payment models. Value-based care <a href="https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Value-Based-Programs.html">links payment to improved population outcomes</a>. This innovative concept has taken the form of <a href="https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/index.html?redirect=/Aco">accountable care organizations (ACOs)</a> - in which groups of doctors or hospitals come together to provide coordinated care to a group of patients while being reimbursed through <a href="http://healthaffairs.org/blog/2014/07/02/the-payment-reform-landscape-bundled-payment/">bundled payments</a>. A bundled payment is a reimbursement method for health care providers, hospitals or other care facilities in which the care provider receives payment for all services to treat a given condition. It differs from fee-for-service, which reimburses a provider for each service - that is, each visit, treatment or test that a patient might receive. Although the goal is to reduce duplication of services while providing high-quality care, these were designed with large, urban populations in mind - as they rely on a high-volume patient population.</p>
<p>Given rural health care’s challenge of caring for aging, sicker patients in areas with low population density, these value-based models <a href="http://www.rupri.org/wp-content/uploads/FORHP-comments-km-DSR-PANEL-DOCUMENT_PRD_Review_112315.clean-4_sn-3.pdf">do not translate well</a> to rural settings. This could result in reducing payments unfairly to rural hospitals, leaving even less money for much needed technology and infrastructure upgrades. </p>
<p>Further, many rural insurance marketplaces are facing increasing rates of insurer dropout and rising premiums due to higher-than-expected costs. This is due to rural populations being much sicker than anyone realized. For example, <a href="http://wvmetronews.com/2016/10/26/obamacare-premiums-spike-in-west-virginia/">patients enrolled in the insurance exchanges in West Virginia</a> were 88 percent more likely to have heart disease, 69 percent more likely to have high blood pressure and 110 percent more likely to have kidney disease compared to nonexchange, privately insured patients. </p>
<p>Even more critical, we are facing a <a href="http://www.modernhealthcare.com/article/20150516/MAGAZINE/305169959">rural hospital closure crisis</a>. The cause of this is <a href="http://kff.org/medicaid/issue-brief/a-look-at-rural-hospital-closures-and-implications-for-access-to-care/">complex</a>, but over 70 percent of the closures have occurred in states that did not expand Medicaid – which appears to be linked to improved finances, as hospitals in expansion states have experienced <a href="http://content.healthaffairs.org/content/35/9/1665.abstract">less uncompensated care</a>.</p>
<h2>What’s to be done?</h2>
<p>To improve rural health, it is critical to maintain the expansion of Medicaid. We must find a way to expand coverage for the rest of rural America – <a href="http://kff.org/uninsured/issue-brief/the-affordable-care-act-and-insurance-coverage-in-rural-areas/">two-thirds of uninsured people in rural areas live in nonexpansion states</a>. As of Jan. 1, 2017, there were 19 states that have not expanded Medicaid. The majority of these states have large rural populations, including those in the Deep South and the stack of western states south of North Dakota.</p>
<p>One option forward for would be to encourage states to apply for special waivers, or 1115 waivers, which allow states a more flexible implementation of Medicaid expansion. For some states, this allows them to expand coverage under Medicaid in a way that is more attuned to each state’s unique demographics and values. For example, alterations range from <a href="https://www.msms.org/Resources/ForPractices/TheHealthyMichiganPlan.aspx">healthy behavior incentives</a> that reduce premiums in Iowa to permitting <a href="http://www.in.gov/fssa/hip/2452.htm">higher cost-sharing</a> than is otherwise allowed under federal rules for nonemergency use of emergency rooms in Indiana. </p>
<p>We do not yet know how the debate over ACA repeal and replace will play out. Yet, we do know that some of the proposed alternatives could result in real harm to rural states - the most obvious being a repeal of Medicaid expansion. Further, block grants have been discussed as a method to control Medicaid costs. These are <a href="http://www.commonwealthfund.org/publications/issue-briefs/2016/nov/medicaid-block-grants">grant programs from the federal government</a> that give states annual fixed amounts to spend on a specific program, but they can result in neglect of rural populations. As block grants limit the amount of money states have to spend on vulnerable populations, they may <a href="https://www.ers.usda.gov/webdocs/publications/aib724/19402_aib72403_1_.pdf">overlook national objectives, such as caring for rural and poor communities.</a></p>
<h2>Danger ahead?</h2>
<p>An immediate repeal of Medicaid expansion and the private marketplaces without a thoughtful transition and comprehensive plan to maintain health insurance coverage will result in catastrophic consequences for rural health. </p>
<p>It will result in a sudden decrease of the insured rates, leading to a dramatic increase in uncompensated care which will likely drive further <a href="http://kff.org/report-section/a-look-at-rural-hospital-closures-and-implications-for-access-to-care-three-case-studies-issue-brief/.">rural hospital closures</a>. This will result in a crisis of access to emergency care and harm rural economies, condemning rural Americans to an unbreakable cycle of poor health and poverty. American identity is steeped in a desire to protect our most vulnerable – but we need to act now to save our heartland.</p><img src="https://counter.theconversation.com/content/71453/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Repeal and replacement of Obamacare would hurt rural health care, causing closure of hospitals and physician practices. What does this mean for a group of people whom Donald Trump has pledged to help?Margaret Greenwood-Ericksen, National Clinician Scholar, Clinical Lecturer, Department of Emergency Medicine, University of Michigan Medical School, University of MichiganMahshid Abir, Assistant Professor, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/697652016-12-09T02:09:42Z2016-12-09T02:09:42ZThe potential costs of Tom Price as HHS secretary<figure><img src="https://images.theconversation.com/files/149292/original/image-20161208-31391-f5c660.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Rep. Tom Price as he arrives at Trump Tower on Nov. 16, 2016.</span> <span class="attribution"><span class="source">, in New York. AP Photo/Carolyn Kaster</span></span></figcaption></figure><p>President-elect Donald Trump has repeatedly vowed to “repeal and replace Obamacare.” A logical question is: With what? The <a href="http://www.nytimes.com/2016/11/29/us/tom-price-trump-health-secretary.html?_r=0">announcement of Rep. Tom Price (R-Ga)</a> as Trump’s nominee for secretary of health and human services provides some answers. </p>
<p>Unlike other Republican critics of the Affordable Care Act (ACA), Price, an orthopedic surgeon, has offered many replacement plans of unmatched detail. His <a href="http://tomprice.house.gov/sites/tomprice.house.gov/files/HR%202300%20Empowering%20Patients%20First%20Act%202015.pdf">Empowering Patients First Act was 242 pages long</a>. It offers a market-based vision for American health care, restricting government involvement. </p>
<p>His plan, however detailed, lacks specifics about what will happen to the 20 million or so who gained insurance coverage under the ACA. This includes people who have preexisting conditions and those who rely on Medicaid, the federal-state program that provides insurance to poor children, pregnant women of a certain income level as well as the disabled and blind under 65. </p>
<p>Price’s policies could also limit access to care for children, women and for many people of all ages with chronic and mental illnesses. </p>
<p>As a scholar of American policymaking, I hope to shed some light on Price’s plan. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/149293/original/image-20161208-31370-1c2r9ur.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/149293/original/image-20161208-31370-1c2r9ur.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/149293/original/image-20161208-31370-1c2r9ur.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/149293/original/image-20161208-31370-1c2r9ur.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/149293/original/image-20161208-31370-1c2r9ur.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/149293/original/image-20161208-31370-1c2r9ur.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/149293/original/image-20161208-31370-1c2r9ur.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">What would Rep. Price do as head of the Department of Health and Human Services?</span>
<span class="attribution"><span class="source">AP Photo/Alex Brandon, File</span></span>
</figcaption>
</figure>
<h2>Children’s coverage could be jeopardized</h2>
<p>One of the main pillars of Price’s plan is tax credits based on age to individuals who wish to buy health insurance in the private market. Importantly, this proposal assumes that those who are younger will also be healthier, thus requiring less coverage. </p>
<p>However, there has been a rise from in the prevalence of chronic illnesses among children, from <a href="http://www.medscape.com/viewarticle/717030">12.8 percent in 1994 to 26.6 percent in 2006</a>. </p>
<p>Also, incidence of type 2 diabetes and teen depression has increased. Mental health conditions <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1925038/">often have an age-of-onset in the teens and 20s</a>. Yet both age groups are allotted the lowest tax credits in the Price plan, and more children from lower- and middle-income households may struggle to obtain needed coverage.</p>
<p>In 2007, Price voted against the reauthorization of the State Children’s Health Insurance Program (SCHIP), a program founded in 1997 that provides medical care to about eight million low-income children, at a <a href="http://www.pewtrusts.org/%7E/media/assets/2014/10/childrens_health_insurance_program_report.pdf">total cost of about US$13 billion</a>. It has been cited as instrumental in reducing the number of uninsured children from <a href="http://www.pewtrusts.org/%7E/media/assets/2014/10/childrens_health_insurance_program_report.pdf">10.7 million in 1997 to 6.6 million in 2012</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/149136/original/image-20161207-18049-1lhvlup.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/149136/original/image-20161207-18049-1lhvlup.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/149136/original/image-20161207-18049-1lhvlup.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/149136/original/image-20161207-18049-1lhvlup.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/149136/original/image-20161207-18049-1lhvlup.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/149136/original/image-20161207-18049-1lhvlup.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/149136/original/image-20161207-18049-1lhvlup.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Application for CHIP.</span>
<span class="attribution"><span class="source">J. David Ake via AP</span></span>
</figcaption>
</figure>
<h2>Medicaid could be rolled back</h2>
<p>Lower-income children are not the only lower-income group likely to suffer under Price’s proposal.</p>
<p>Currently, federal and state governments share the cost of Medicaid, with 32 states having adopted the Medicaid expansion that was called for under the ACA. An ACA repeal would eliminate expansions of Medicaid and the Children’s Health Insurance Program (CHIP) – <a href="http://www.usnews.com/news/articles/2015/02/24/medicaid-enrollment-surges-across-the-us">which together cover approximately one in five Americans</a> – and replace it with Medicaid block grants that the federal government provides to the states. </p>
<p>This would <a href="http://bipartisanpolicy.org/blog/paul-ryans-fiscal-year-2014-budget-details/">slow the growth annual rate of spending on Medicaid from its current level of 7 percent to 3 percent</a>, according to the Congressional Budget Office. The CBO also estimated a reduction in Medicaid spending by <a href="http://www.vox.com/policy-and-politics/2016/11/29/13778622/price-trump-medicaid-block-grants">$1 trillion over 10 years</a>. </p>
<p>But The Medicaid programs that Price seeks to restrict not only are more cost-effective in the long run to administer – with the <a href="http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2016/rwjf419097">Robert Wood Johnson Foundation estimating</a> that Medicaid coverage expansion reduced hospitals’ uncompensated care by 21 percent, with states saving in costs of caring for the uninsured – but have had demonstrably positive health outcomes for vulnerable populations. For example:</p>
<p>A <a href="http://content.healthaffairs.org/content/32/6/1037.abstract">study in the public health journal Health Affairs</a> suggested that outpatient medical appointments increased 29 percent, while preventable hospitalizations fell 48 percent in the aftermath of a new new public insurance program in Wisconsin in 2009.</p>
<iframe src="https://datawrapper.dwcdn.net/e6L61/2/" frameborder="0" allowtransparency="true" allowfullscreen="allowfullscreen" webkitallowfullscreen="webkitallowfullscreen" mozallowfullscreen="mozallowfullscreen" oallowfullscreen="oallowfullscreen" msallowfullscreen="msallowfullscreen" width="100%" height="320"></iframe>
<p>Also, <a href="http://kff.org/medicaid/issue-brief/the-effects-of-medicaid-expansion-under-the-aca-findings-from-a-literature-review/">The Kaiser Family Foundation reported in 2016</a> that Medicaid expansion under the ACA not only reduced the uninsured rates of those states, but in many cases improved access to care and utilization of some physical and behavioral health services. Similarly, an Urban Institute <a href="http://www.urban.org/sites/default/files/alfresco/publication-pdfs/412707-The-Cost-and-Coverage-Implications-of-the-ACA-Medicaid-Expansion-National-and-State-by-State-Analysis.PDF">report</a> on outcomes related to Medicaid showed greater access. </p>
<h2>Those with preexisting conditions could lose out</h2>
<p>In the aftermath of meeting with President Obama, <a href="http://www.cnn.com/2016/11/11/politics/donald-trump-obamacare-interview/">Trump indicated some interest</a> in preserving the provision that people cannot be denied insurance coverage for preexisting conditions. </p>
<p>This is challenging, however. Insurers’ ability to guarantee coverage regardless of preexisting conditions works in <a href="https://theconversation.com/why-repealing-obamacare-may-not-be-as-easy-as-trump-thinks-68562">tandem with the ACA’s mandate </a>that all individuals enroll in at least some level of coverage. The purpose of this was to bring healthy patients into the risk pool.</p>
<p>Price’s plan would prevent insurers from denying coverage based on preexisting conditions, but at a price. His plan would allow insurers to charge consumers <a href="http://tomprice.house.gov/sites/tomprice.house.gov/files/HR%202300%20Empowering%20Patients%20First%20Act%202015.pdf">up to 150 percent of standard premiums</a>. This would apply if consumers do not maintain continuous coverage for at least 18 months. Thus, if someone becomes unemployed and unable to afford coverage in between jobs, he or she could be left without insurance. </p>
<p>Such a marked premium increase could in some cases be devastating, especially for those with chronic conditions. <a href="http://www.cdc.gov/chronicdisease/overview/">The Centers for Disease Control and Prevention estimated</a> in 2012 that about half of the American population (117 million) had at least one chronic health condition, and one in four adults has two or more chronic health conditions. <a href="http://www.cdc.gov/chronicdisease/overview/">Seven of the top 10</a> causes of death are chronic diseases. </p>
<h2>Mental health treatment could suffer</h2>
<p>Within the context of preexisting conditions, it is worth emphasizing also that the CDC estimate focused on behavioral and not mental health, the diagnosis of which would also constitute a preexisting condition. </p>
<p>Yet about <a href="https://www.nimh.nih.gov/health/statistics/prevalence/major-depression-among-adults.shtml">16.1 million Americans</a> had a major depressive episode in the past year, which does not include milder forms of depression, or other behavioral health conditions such as anxiety or psychotic disorders. Indeed, about <a href="http://www.nami.org/Learn-More/Mental-Health-By-the-Numbers">one in five American adults</a> will struggle with mental illness in a given year. </p>
<p>The ACA provided a marked expansion in access to care for mental and behavioral health by requiring that most individual and small group plans and all marketplace plans provide mental health benefits. The repeal of the ACA leaves the state of mental health care very much in question. It renders particularly vulnerable those who have capitalized on the ACA’s access to mental health coverage and in doing so, accumulated preexisting conditions.</p>
<h2>Women’s health could be harmed</h2>
<p>In his first term in Congress, Price cosponsored the Right to Life Act, which sought to extend 14th Amendment personhood to a fertilized egg and thus limit abortions. This did not make exceptions for pregnancies resulting from rape or incest, and it did not consider the health of the woman. </p>
<p>Price did not simply vote for legislation to defund Planned Parenthood (HR 3134 in 2015); he cosponsored it. </p>
<p>The defunding of Planned Parenthood could limit care to women, given that it provides contraception, STD testing, cancer screenings and prenatal care. Increased <a href="https://www.guttmacher.org/gpr/2014/09/what-behind-declines-teen-pregnancy-rates">contraceptive use has been the main reason for a dramatic decline in teen pregnancies</a> in recent decades.</p>
<p>Women in urban areas can obtain contraceptive care from many sources in urban areas, <a href="http://healthaffairs.org/blog/2015/09/08/quantifying-planned-parenthoods-critical-role-in-meeting-the-need-for-publicly-supported-contraceptive-care/">but Planned Parenthood is the sole provider in one fifth of 491 counties </a>surveyed in 2010. And in two-thirds of those counties, Planned Parenthood clinics served at least half of the women who obtained contraceptive care from safety-net health centers. </p>
<h2>Who is empowered?</h2>
<p>After the American Medical Association endorsed Price, <a href="https://medium.com/@ClinicianAction/the-ama-does-not-speak-for-us-d697511267d5#.h546k74rf">an open letter signed by over 5,000 physicians</a> challenged the endorsement. </p>
<p>The empirical evidence in favor of the programs that he seeks to scale back or eliminate altogether should temper his eagerness to overhaul the Affordable Care Act. </p>
<p>Such tempering is not yet apparent. How Senate Democrats and moderate Republicans – perhaps those in states that accepted and benefited from Medicaid expansion – respond to Price in the looming confirmation battle may provide some answers to who is empowered first under Price’s leadership.</p><img src="https://counter.theconversation.com/content/69765/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Miranda Yaver does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Donald Trump’s pick for head of Health and Human Services marks a sharp departure from the direction of HHS under President Obama. Here’s a look at who might be affected by Tom Price’s leadership.Miranda Yaver, Lecturer in Political Science, Yale UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/675292016-10-26T03:24:08Z2016-10-26T03:24:08ZHere’s how the next president could work with Congress to fix Obamacare<p>As we all know by now, The Donald <a href="https://theconversation.com/could-the-candidates-truly-fix-or-nix-obamacare-six-essential-reads-67353">wants to repeal and replace</a> the Affordable Care Act while <a href="https://theconversation.com/could-the-candidates-truly-fix-or-nix-obamacare-six-essential-reads-67353">Hillary wants to fix it</a>. But what does that mean, and how would they do it?</p>
<p>The first question is what exactly do they want to repeal or fix. The ACA seems to have evolved into a great political Rorschach test somewhat devoid of real content but relying on projection of underlying beliefs.</p>
<p>For Republicans, it is evidence of governmental overreach and excess expenditures, while Dems seem to think of it as the essence of collective action and shared responsibility for those less fortunate. As such, neither informs the specific directions we might take from here.</p>
<p>In reality, the <a href="http://www.healthline.com/health-slideshow/most-important-aspects-of-the-affordable-care-act">ACA </a>consists of four major parts: </p>
<ol>
<li>Expansion of Medicaid for low-income working poor, with mostly federal financing.</li>
<li>Research on alternative ways to treat conditions to inform physician practice.</li>
<li>Tests of innovative ways to organize and deliver health care for better value that can be quickly implemented across the system. </li>
<li>The exchanges, for purchasing subsidized individual policies from private insurance companies.</li>
</ol>
<p>Of course, it is mainly the exchanges that get public attention and, unfortunately, much of that is misinformed. And even if the candidates were to change or eliminate the exchanges, the other three parts, which may well be the most important and lasting legacy of the legislation, would most likely stand.</p>
<h2>Medicaid madness?</h2>
<p>The easiest part of the ACA was thought to be the <a href="https://www.medicaid.gov/medicaid/program-information/downloads/modified-adjusted-gross-income-and-medicaid-chip.pdf">expansion of Medicaid to the working poor</a>, but it became a political battle. Medicaid expansion cuts states’ health care costs while providing coverage to millions more people.</p>
<p>The expansion required <a href="http://healthaffairs.org/blog/2016/03/21/the-economics-of-medicaid-expansion/">no expenditure of state money for the first three years</a>, only an acceptance of federal dollars. Thus, many considered expansion a done deal and a crucial part of the law. Then the U.S. Supreme Court <a href="http://www.scotusblog.com/2012/06/court-holds-that-states-have-choice-whether-to-join-medicaid-expansion/">ruled that states could refuse </a>to expand Medicaid.</p>
<p>Many – 26, to be precise – did just that in 2014, as Republican governors and lawmakers in red states voted to not accept the federal money. Some later changed their minds, but as of now, <a href="http://kff.org/health-reform/slide/current-status-of-the-medicaid-expansion-decision/">19 states still have not expanded Medicaid</a>.</p>
<p>Even some<a href="http://politics.blog.ajc.com/2016/08/31/georgia-chamber-pitches-conservative-friendly-blueprint-for-medicaid-expansion/"> red state governors</a> who resisted the extra funds from the Feds to expand Medicaid coverage are reconsidering, albeit with some conditions that provide political cover. Only states’ rights advocates, for philosophical reasons, and budget hawks, who fear that the Feds will renege on their funding, are holding out for a repeal of this one.</p>
<h2>Beyond the exchanges</h2>
<p>While the double-digit premium increases have led to calls for repeal, it’s important to look at the law more broadly and what can be done to fix it.</p>
<p>Two parts of the ACA <a href="https://www.cms.gov/apps/files/aca-savings-report-2012.pdf">may have dramatic impact </a>even though they totally avoid public scrutiny. They seek to change the way that health care is delivered at a very fundamental level. Research <a href="http://obamacarefacts.com/summary-of-provisions-patient-protection-and-affordable-care-act/">called for by the ACA</a> is being done by health care systems, insurers, and provider at every level, focusing on alternative ways to treat problems – something that most would assume we already do. Under the law, <a href="https://www.ncbi.nlm.nih.gov/books/NBK241388/">reimbursements to providers</a> is tied to their doing this.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/143156/original/image-20161025-4735-j1bu93.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/143156/original/image-20161025-4735-j1bu93.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=659&fit=crop&dpr=1 600w, https://images.theconversation.com/files/143156/original/image-20161025-4735-j1bu93.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=659&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/143156/original/image-20161025-4735-j1bu93.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=659&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/143156/original/image-20161025-4735-j1bu93.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=828&fit=crop&dpr=1 754w, https://images.theconversation.com/files/143156/original/image-20161025-4735-j1bu93.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=828&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/143156/original/image-20161025-4735-j1bu93.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=828&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The FDA approves drugs in the U.S. Via Shutterstock.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-133102730/stock-photo-prescription-pill-bottle-spilling-pills-on-to-surface-isolated-on-a-white-background.html?src=YqWfTo13h1Xrijxg-_OdAQ-1-16">From www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>But that’s not really the case. For example, the <a href="http://www.fda.gov/Drugs/DevelopmentApprovalProcess/">FDA is charged with assuring that a drug</a> or device is effective (efficacious) and safe (not toxic or carcinogenic), not whether it is actually better than the alternative. So we have alternative drugs, devices, surgeries and so forth that all address a problem with little guidance as to which one actually is better. </p>
<p>The idea is that scientific findings will guide both <a href="http://obamacarefacts.com/summary-of-provisions-patient-protection-and-affordable-care-act/">physician practice and coverage decisions</a> toward better value and blunt that drive toward more marginal treatment at ever higher cost with limited outcomes. </p>
<p>The alternative approach to this kind of cost control is just to <a href="https://hbr.org/2014/11/how-not-to-cut-health-care-costs">cut payments, while allowing volume to expand</a>. It is unlikely that those who support cost control and those who do not will want to proceed down that path. It will lead to bankruptcy and ever declining marginal value – although those who stand to lose money may resist.</p>
<p>In a similar way, the Innovation Center <a href="https://www.cms.gov/apps/files/aca-savings-report-2012.pdf">called for in the ACA </a>is designed to try new organizational and payment models to see what works better and encourage adoption widely. The goal here is “value,” where that is defined as something that meets at least threshold quality metrics (e.g., hospital readmission rates) while meeting or beating actuarial estimates of cost.</p>
<p>The only ones who are arguing against these two little known parts of the act are those whose vested interests would be challenged. Drug companies are not wild about the additional standards of value for their products; hospitals argue the quality metrics are faulty, and physicians don’t like being forced into new organizations that may limit their autonomy. </p>
<p>Big bets have been made on the future of health care, and these cannot be recalled easily. But there are places here that will likely be part of Hillary’s “fixing” of the ACA.</p>
<h2>And then there are marketplaces</h2>
<p>So that leaves us with the “disaster” of the individual insurance markets decried by Trump, who has said he would eliminate the marketplaces in favor of open competition across state lines. Allowing insurance companies to offer insurance in different states, the thinking goes, will increase competition of plans and lower rates for consumers. </p>
<p>Unfortunately, the companies don’t seem interested <a href="http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2012/rwjf401409">since they already can do this to some extent</a> but don’t. One reason is that premiums are based, in part, on <a href="http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2012/rwjf401409">negotiated rates with providers</a>. It is hard to build provider networks in another state, from another state. </p>
<p><a href="http://healthaffairs.org/blog/2013/03/06/no-competition-the-price-of-a-highly-concentrated-health-care-market/">The level of competition insurers face is secondary</a> and may be a detriment in driving provider rates lower. </p>
<p>In any event, cross-border competition hardly is a panacea for rising costs. It is, however, an unspoken attack on the insurers as a way to break their often solid capture of the regulation process which now resides at the state level. Thus, expect industry resistance to this traditional Republican proposal.</p>
<p>The problems of the individual insurance exchanges come from many directions. Besides insurance company pricing errors compounded by their natural risk avoidance, the government changed the rules midstream and limited the range of premiums insurers can charge, which forced the young to pay too much or the old too little. </p>
<p>This was compounded by a <a href="https://theconversation.com/whats-ailing-the-aca-insurers-or-congress-64151">huge failure of Congress to hold up their end of the bargain</a> in supporting the transitional support promised by the law to companies willing to take the plunge into the unknown of the exchanges, as I wrote about in The Conversation in August. When<a href="https://theconversation.com/whats-ailing-the-aca-insurers-or-congress-64151"> only 12 percent of the support </a>promised to companies with higher than expected costs was paid, the higher risk and big losses drove many out of the markets. Thus, many of the problems of the exchanges lie directly at the feet of Congress. </p>
<p>A Democratic Congress would rectify this as part of the fix. Hillary also<a href="http://www.forbes.com/sites/brucejapsen/2016/05/15/hillarys-medicare-buy-in-could-replace-vanishing-retiree-coverage/#52a3a52a45eb"> would allow people in the 55-64-year-old age</a> group to buy into Medicare early. This is a form of the <a href="http://www.factcheck.org/2009/12/public-option-vs-single-payer/">“public option”</a> that would be popular and probably would enliven the areas where there is no competition on the exchanges. </p>
<p>The irony of the Republican opposition to the use of a competitive market with subsidies to make health insurance “affordable” – essentially their long time alternative – might become apparent, allowing them to engage in fixing the ACA if Congress goes blue.</p>
<p>Interestingly, Clinton has a number of <a href="http://time.com/money/4327009/hillary-clinton-medicare-proposal-3-questions/">other positions </a>that one could argue would move us toward lower cost and higher quality as promised by the ACA. One of the most interesting concerns <a href="https://www.hillaryclinton.com/briefing/factsheets/2016/09/02/hillarys-plan-to-respond-to-unjustified-price-hikes-for-long-available-drugs/">drugs</a>, where she would allow Medicare to bargain for lower prices, permit importation of price-controlled prescription pharmaceuticals from other countries and limit direct-to-consumer advertising. </p>
<p>Given that this is the <a href="http://healthaffairs.org/blog/2015/08/31/rising-cost-of-drugs-where-do-we-go-from-here/">most inflationary of any sector of health care </a>and that many firms seem to have engaged in exploitative pricing, these are likely to get attention from both sides of the aisle although Republicans have said little about their approach.</p>
<p>So overall, it is unlikely that we would actually see a full “repeal and replace” from the GOP. There are some signs that Congress is open to fixing the ACA, as evidenced by a few Republicans, such as Rep. <a href="http://www.bloomberg.com/politics/articles/2016-08-23/clinton-win-could-pressure-gop-to-heal-not-repeal-obamacare">Dennis Ross of Florida</a>. Realistically, in their weakened position should Trump lose, compromise is more likely than in any time during the last eight years. </p>
<p>The fact that the ACA actually has <a href="http://www.usnews.com/opinion/economic-intelligence/2014/06/20/cbo-confirms-obamacare-reduces-deficits">reduced the deficit</a>, although estimates vary by how much, and <a href="http://www.forbes.com/sites/brucejapsen/2016/10/23/hillarys-right-obamacare-reduces-medicare-spending/#6484d47666ab">extended Medicare solvency</a> by many years may mean that wholesale changes would not be good. It would be important to keep those parts that have saved money. And both sides have pledged their allegiance to both of these politically popular objectives.</p>
<p>Going forward, the most likely path is the same difficult one that the U.S. system as a whole must take toward improving access and value. There will be no quick fix.</p><img src="https://counter.theconversation.com/content/67529/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>JB Silvers is affiliated with MetroHealth Medical Center, Cleveland (board).</span></em></p>Double-digit premium increases are leading to an outcry that the Affordable Care Act is not working, yet parts of it are. Here’s what works, and ideas on how to fix what doesn’t.J.B. Silvers, Professor of Health Finance, Case Western Reserve UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/664722016-10-12T02:20:12Z2016-10-12T02:20:12ZLove it or hate it, Obamacare has expanded coverage for millions<p>The most significant pieces of the Affordable Care Act (ACA), or “Obamacare,” were implemented in 2014. These include expanding Medicaid in many states, the establishment of insurance exchanges with subsidized coverage and the individual mandate, which requires individuals to purchase health insurance.</p>
<p>One aim of the law was to expand coverage to the very poor. That was to be done by expanding <a href="https://www.medicare.gov/your-medicare-costs/help-paying-costs/medicaid/medicaid.html">Medicaid</a>, a joint federal-state insurance program for the poor and disabled. Medicaid is generally funded by the federal government with matching grants to the states, which administer the plan. </p>
<p>Under the ACA, the federal government <a href="http://kff.org/health-reform/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid-an-update/">offered money to states</a> to expand Medicaid to those at or below 138 percent of the federal poverty line. The expansion became politicized, however, and many states chose to forgo the federal money and not expand. As of today, 19 states have not expanded Medicaid. As a result, about <a href="http://kff.org/health-reform/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid-an-update/">three million poor people </a> across the country did not gain the coverage that the law originally intended.</p>
<p>Even so, <a href="http://www.commonwealthfund.org/publications/in-the-literature/2014/jul/coverage-under-affordable-care-act-progress-report">several studies</a> have since documented large gains in insurance coverage between 2013 and 2014 for other groups of uninsured people. One natural question is: How much of these gains in coverage came from the ACA? Could the higher number of insured people have come from other factors, notably a better economy?</p>
<p>In a recently released <a href="http://www.nber.org/papers/w22182">National Bureau of Economic Research</a> working paper, we use data from the American Community Survey (ACS) to answer this question. We find that the ACA led to a 5.9 percentage point gain in insurance coverage in Medicaid expansion states and a 3.0 percentage point gain in coverage in nonexpansion states.</p>
<p>President Obama himself<a href="http://jama.jamanetwork.com/article.aspx?articleid=2533698"> cited our work</a> as supporting the claim that the ACA is the primary cause of recent national gains in coverage in his much-publicized article about the ACA in the Journal of the American Medical Association (JAMA).</p>
<p>With the election only weeks away, the ACA is going into its fourth open enrollment period. With some <a href="https://theconversation.com/whats-ailing-the-aca-insurers-or-congress-64151">insurers having exited </a>the ACA marketplace, causing premiums to rise, many Americans are asking whether the law is in peril.</p>
<p>If you look at our numbers, however, it is hard to escape the fact that it has helped <a href="http://www.hhs.gov/about/news/2016/03/03/20-million-people-have-gained-health-insurance-coverage-because-affordable-care-act-new-estimates">20 million</a> people over three years gain insurance coverage – one of the law’s primary objectives.</p>
<h2>Disentangling the Medicaid numbers</h2>
<p>One of the major contributions of our NBER working paper is to separately evaluate the impact of the Medicaid expansion from the other components of the ACA. </p>
<p>We accomplish this by taking advantage of both the fact that some states expanded their Medicaid programs under the ACA while others did not. Also, within a given state one would have expected larger gains in coverage to come from areas with larger pre-ACA uninsured rates. This analysis allows us to disentangle the causal effect of the ACA from the underlying time trend in insurance coverage.</p>
<p>For example, we estimate that the ACA including the Medicaid expansion increased insurance coverage by 5.9 percentage points. This is calculated using the average local area pre-ACA uninsured rate. The effect reached as high as 15.4 percentage points in the area with the highest uninsured rate. </p>
<p>The effect of the other components of the ACA without the Medicaid expansion was only 3.0 percentage points at the average uninsured rate, reaching as high as 7.8 percentage points. </p>
<h2>A look at employer plans and individual plans</h2>
<p>We also examine gains by type of coverage, finding that coverage gains in non-Medicaid expansion states came entirely from private insurance, divided evenly between gains in employer-sponsored insurance (ESI) and non-group coverage.</p>
<p>This result is unexpected and interesting for two reasons. </p>
<p>First, the ACA was not designed to alter the employer-provided insurance market. Also, the employer mandate had not yet been implemented in 2014. Because of that, we might have expected a smaller effect on ESI.</p>
<p>These gains in work-related coverage may represent employees, their spouses or their dependents responding to the individual mandate by increasing their take-up of ESI. </p>
<p>Second, because <a href="http://www.hhs.gov/about/news/2014/05/01/enrollment-health-insurance-marketplace-totals-over-8-million-people.html">eight million people enrolled </a>in the exchanges in 2014, we might have expected a larger effect on non-group coverage. </p>
<p>Our back-of-the-envelope calculations suggest that only 27 percent of people who purchased a plan through the exchanges were newly covered. That being said, even if individuals with exchange plans already had some form of pre-ACA coverage, the quality of their coverage may have improved along several dimensions, such as the range of services covered. </p>
<p>Coverage gains from the Medicaid expansion can be attributed solely to increased Medicaid coverage. We find no evidence that individuals dropped their private coverage in order to enroll in newly offered public coverage.</p>
<h2>Who was signing up?</h2>
<p>Finally, we estimate how gains in coverage differed by different demographic groups.</p>
<p>The increases in coverage from the ACA with the Medicaid expansion were largest for those without a college degree, nonwhites, 19-34-year-olds, unmarried individuals and those without children in the home. </p>
<p>These subgroup findings have important implications with respect to disparities in coverage. For instance, our estimates imply that the fully implemented ACA reduced the coverage gap between the lowest and highest education groups by 11.4 percent. Without the Medicaid expansion, this gap is lowered by only 6.7 percent. </p>
<p>The ACA with the Medicaid expansion reduced the coverage gap between whites and nonwhites by 2.0 percentage points (14 percent). The ACA without the Medicaid expansion actually increased this gap in coverage.</p>
<h2>New data will show trends</h2>
<p>One limitation of our paper is that we estimate only the effects in the first year of full ACA implementation, due to data availability. </p>
<p>It would certainly be valuable to revise our estimates as additional waves of the ACS become available. The number of people who purchased an exchange plan increased from 8 million in 2014 to 8.8 million in 2015, and 12.7 million have selected an exchange plan in 2016. </p>
<p>Large increases in the maximum size of the individual mandate penalty in both 2015 and 2016 may lead to increases in the impact of the ACA on individually purchased and overall coverage. </p>
<p>Additionally, several states (Pennsylvania, Indiana, Alaska and Montana) have elected to expand their Medicaid program in 2015 or 2016. The employer mandate will come into play in the future as well. </p>
<p>Though these subsequent changes may lead to further coverage increases, higher-than-expected <a href="https://theconversation.com/whats-ailing-the-aca-insurers-or-congress-64151">exchange premiums and insurer exits </a>from the exchange market could actually reduce coverage. </p>
<p>The motivation for this work was to provide crucial evidence about the early effects of the ACA that may potentially inform ongoing debates regarding health policy.</p>
<p><em>To read the full report, click here: <a href="http://www.nber.org/papers/w22182">http://www.nber.org/papers/w22182</a></em></p><img src="https://counter.theconversation.com/content/66472/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Charles Courtemanche receives funding from the National Institutes of Health and United States Department of Agriculture work unrelated to the research discussed here.. </span></em></p><p class="fine-print"><em><span>Jim Marton does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The Affordable Care Act increased the number of insured people, but skeptics have suggested the increase could be due to higher employment rates. That’s not the case, a detailed study suggests.Jim Marton, Associate Professor, Economics, Georgia State UniversityCharles Courtemanche, Department of Economics, Usery Workplace Research Group, Georgia State UniversityLicensed as Creative Commons – attribution, no derivatives.