Headline bombshells about James Comey, Donald Trump, and the Russian connection continue to explode at an alarming pace. But the future of health care — which is a little under the radar at the moment — is more salient for most Americans, as Jimmy Kimmel’s recent heartfelt monologue should remind us.
New polls from Quinnipiac and Public Policy Polling show Democrats with double-digit leads in polls about hypothetical "generic" candidates in congressional elections, largely thanks to the health care issue. Quinnipiac reported that Democrats' 54 percent to 38 percent favorability margin over Republicans was “the widest . . . ever measured for this question" in its poll. PPP headlined its press release, “Health Care Puts House in Play,” and reported that the Democrats' 11-point lead over Republicans had risen from 6 points a month ago and was dramatically higher — 61 percent as opposed to 34 percent — among voters who said they were "very excited" to cast ballots next year.
Republicans know they’ve got a serious problem here. Their heart’s desire rests on massively slashing Medicaid, the federal health care program for lower-income people. So they are now forced to pretend those huge cuts won’t have any ill effects.
"You don't think anyone's going to be hurt by taking $880 billion out of the system?" George Stephanopoulos asked House Speaker Paul Ryan on ABC's "This Week." "No, no, I don't," the House speaker responded. "Because I think the micromanagement of Medicaid by the federal government, the Medicaid system isn't working."
White House press secretary Sean Spicer said recently, “More and more Medicaid recipients aren’t actually able to get coverage.” He added, “Again, it's one thing to have a card. It’s another thing to walk into a doctor's office and then to [have them] tell you, 'We no longer accept Medicaid anymore.' That’s not care.”
As these examples show, Republicans rhetorically claim to be empowering both state governments and individual patients. That’s in line with how they have always approached health care as an ideological project, as political scientist David Hopkins described for Salon in April:
Health care debates often take the form of Democrats arguing in favor of specific policies [while] Republicans respond by saying, “That’s big government, that’s infringing on individual liberty, that’s violating free market principles,” and so on. The entire time we’ve been debating health care in this country as a federal issue, going all the way back to the 1930s and ’40s, the debate has taken that form.
But the facts undercut this position, according to Hannah Katch, a senior policy analyst with the Center on Budget and Policy Priorities who is deeply familiar with both individual-level health outcomes and how health systems work at the state level. She pointed out that Medicaid expansion and private marketplace subsidies serve a common purpose, one that Republicans work overtime to obscure.
“The Affordable Care Act helped low- and moderate-income families who are often working in low-wage jobs, but do not have employer-based health coverage," Katch told Salon. "The combination of the Medicaid expansion and the Affordable Care Act tax credits helped people who were working, had some income, but didn't have access to affordable health coverage before. Those are two of the provisions that are at risk right now, in addition to the Medicaid caps.”
Medicaid — a central federal welfare-state program, alongside Medicare and Social Security — has been on the GOP’s wish-list chopping block for decades, making it a logical point of focus.
“The House-passed bill to repeal the Affordable Care Act would cap states’ Medicaid funding, severely damaging the program and threatening care for millions of seniors, children, and people with disabilities,” Katch explained. "New data from the Commonwealth Fund show that today, Medicaid provides essential, high-quality care to millions of Americans.”
In a recent Center on Budget and Policy Priorities blog post, Katch highlighted five charts summarizing key Commonwealth Fund findings. The first three charts focus on the adequacy of health care for Medicaid recipients, in contrast to those with private insurance and those who were uninsured over all or some of the previous year.
On the crucial issue of having a regular health care provider, Medicaid recipients had providers at rates very similar (91 percent) to the privately insured (93 percent) and much higher than the uninsured (77 percent).
Second, on this issue of quality of care, Medicaid beneficiaries were slightly more likely than those who were privately insured to say their care was excellent or very good: That was 57 percent of the respondents compared with 52 percent.
Third, Medicaid beneficiaries received preventative services at rates comparable to the privately insured, and significantly higher than the uninsured. The rates for three key services were as follows:
Pap tests: those with Medicaid, 77 percent; people with private insurance, 79 percent; uninsured, 67 percent.
Mammograms: those with Medicaid, 71 percent; people private insurance, 75 percent; uninsured, 49 percent.
Colon cancer screening: Medicaid, 62 percent; people with private insurance, 62 percent; uninsured, 42 percent.
But perhaps most shocking — especially in light of conservative rhetoric — was how much better Medicaid recipients fared economically compared to the privately insured and how that impacted their health. The fourth chart showed how much more affordable Medicaid coverage is. Only 12 percent of the Medicaid beneficiaries had problems paying bills, compared with 20 percent of those with private insurance and 35 percent of the people without insurance. The numbers differed, but the pattern was the same when it came to reporting being contacted by collection agencies and, most crucially, for not seeing a specialist when one was needed:
In fact, Medicaid’s superiority is not limited to people having the chance to see specialists. Across the board, as the fifth chart showed, Medicaid beneficiaries were less likely to forgo needed care due to cost than either privately insured or uninsured people. They were roughly half as likely to not see a doctor when they had a medical problem or not to fill a prescription and were dramatically less likely to forgo a medical test. Unsurprisingly, the uninsured fare much worse on all three metrics:
This last chart represents the real bottom line in terms of how effective Medicaid is at delivering the health care people need most. Medicaid turns out to do that significantly better than private insurance does — which is the exact opposite of what the GOP’s narratives insist.
The focus on individual health outcomes is important, obviously. But the GOP is also completely wrong on another front — rather than “empowering states,” as Republicans claim to do, the changes they long to introduce will do the opposite, Katch explained.
“The House-passed bill would replace the flexible funding structure that we have now with a very rigid per-capita cap,” Katch said. “It would break the federal government’s historical promise to cover its share of states’ Medicaid spending, shifting a huge amount of the cost and financial risk to states, and creating huge holes in states’ budgets.”
By raising financial costs and risks, the GOP bill "would undermine a lot of the flexibility that states have to be innovative in their health care programs today,” Katch said. “States are amazingly innovative" when it comes to how they deliver Medicaid, she explained. “Rigid, one-size fits all caps would eliminate this flexibility for states.”
As the data given above suggests, “Medicaid is the most efficient health care program we have," Katch noted, "more efficient than commercial insurance while covering a more expensive population. States have found groundbreaking ways to deliver care for their communities, and it's because of Medicaid’s flexible structure that they been able to do that.”
The structure has been flexible, while the funding has been assured — exactly the combination that states need. “Innovation often requires an upfront investment," Katch said. "In order to invest in Medicaid, states have to have reliable funding. Under the House bill’s caps, states would quickly struggle to figure out how they're going to pay for basic services. They're not going to be able to invest in innovative ways to improve care for the Medicaid population.”
One example Katch cited is "care coordination," a concept that bears some explanation:
A number of states have created "health homes" for people with multiple, chronic conditions – people who have a mental health condition or opioid addiction, and may also have another chronic health condition, like diabetes. By giving these people some help navigating the health care system, states can help improve health and may be able to reduce costs over the long term. Medicaid caps will force states to ration care, rather than giving them the flexibility to invest in innovative programs like health homes.
Another example was pioneered by just one state, she explained:
Oregon has created "coordinated care organizations," partnerships between providers and Medicaid health plans, which have been able to significantly improve coordination of care for some of their sickest patients. Oregon recently announced [it has] been able to reduce the number of avoidable emergency room visits by half. But it costs money to invest in new ways to provide care, and it also requires the states to accept some financial risk, which they won’t be able to do if they are struggling to figure how they're going to pay for basic services under a Medicaid cap.
The House GOP rushed its bill through frantically, without even holding a single hearing, giving no time at all for a coherent public debate. However much the GOP's Senate leaders might want to do the same, it seems unlikely they can match the House for pure speed and secrecy. Once the doors are opened to public testimony, evidence like that cited by Katch — both about individual impacts and state-level systems — will have to be heard, provided there’s an organized effort to demand it. The time for concerned citizens to become deeply familiar with the evidence is now, before Senate Republicans attack.