If expanding Medicaid is so much easier, why was the administration so intent on focusing on the exchanges — and, for that matter, why were exchanges needed in the first place?
To Drew Altman, president of the Kaiser Family Foundation, this exposes a core reality of U.S. health-care politics. “Republicans don’t like entitlement programs, and Democrats want to portray the ACA as mostly a marketplace solution based on private insurance and not another expansion of a government program,” he says, “so neither side wants to emphasize the ACA’s success enrolling people in Medicaid even though it may be the law’s biggest achievement so far in terms of expanding coverage.”
This has left both the Obama administration and Republicans in a tight spot.
The White House can’t really tout the Medicaid expansion because it’ll revive fears on the right that Obamacare is really a stealthy effort to create a single-payer health-care system, and it’ll arouse criticism on the left that the administration should have expanded Medicaid to all. As for Republicans, they can’t admit the Medicaid expansion is going well because doing so is dangerously close to advocating a single-payer health-care system. The exchanges, marred by their troubled introduction, are also a problem as they are a Republican idea, enshrined in Representative Paul Ryan’s health-care bill.
Scheiber believes that the Medicaid expansion could pave the path to single-payer:
[T]here will likely be millions of white working-class voters on Medicaid in the coming years. (Even in some conservative states, like Arkansas, Kentucky, and West Virginia.) Once that happens, something tells me Republicans will become more charitably-disposed to the program.
Then there’s the likelihood that, one day soon, especially if Medicaid becomes more generous, the working-class person who makes 175% of the poverty level will look at his working-class neighbor making 130% of the poverty level and think, wow, his health insurance seems a lot better than my private Obamacare plan. How long can it be before most people earning 175% or 200% of the poverty level are allowed to buy in, too?
Suderman disagrees:
Scheiber’s theory … overlooks how tough passage of Obamacare was in the first place—and how much support the administration had to get from health industry stakeholders in order to eke out a legislative victory. Single payer would be even tougher. Moderate Democrats who were nervous about Obamacare the first time around would be even less likely to support single payer, especially given how the law cost Democrats at the voting booth. And there’s no way that doctors, insurers, hospitals, and other major health industry groups would play nice with a single-payer push. Quite the opposite: Even beyond the insurers, much of the industry would see single-payer as a de facto nationalization of the health system, and they would fight the transition with everything they could muster.
Drum’s view:
I think Medicaid expansion is great, but unlike a lot of lefties, I also think it’s a dead end. It’s not going to lead to single-payer, and it’s never going to be a template for future health care reforms. The marketplaces, despite all their problems, have far more potential to eventually lead to health care coverage for all. I think they also have more potential to produce delivery reforms down the road and to rein in cost growth. For that reason, I’m OK with the Medicaid expansion staying under the radar. That’s a fine place for it.
The Dish 