When you make something cost more, fewer people can afford it. Your remedial mathematics lesson for this week is sponsored by the state of Indiana, where a popular conservative experiment with making poor people pay for Medicaid is indeed severely depressing access to health care.
The state’s version of Medicaid expansion under Obamacare is often touted as a model for conservative politicians who are unwilling to broaden eligibility for the health insurance program unless they get permission to tack on additional rules and costs.
But the plan, enacted by then-Gov. Mike Pence and largely written by President Donald Trump’s current chief Medicaid and Medicare official Seema Verma, is having precisely the grim results predicted by health care policy experts before it became law in 2015.
While Pence’s plan theoretically extended Medicaid coverage to some 590,000 individual residents so far, the majority of them have seen their coverage cut back or canceled according to a new report on the plan’s outcomes. While just 13,550 people were kicked off the Medicaid roles in that time, another 287,000 got knocked down into a reduced service category that does not include vision or dental coverage. More than 46,000 never enrolled to begin with.
Why is Pence’s plan delivering so much less actual insurance coverage to so many fewer actual human beings than it was supposed to? The Vice President felt it was important that people with incomes below 139 percent of the federal poverty level have “skin in the game” for their health care. He imposed premiums on this economically vulnerable population, a policy directly at odds with the core purpose of the Medicaid program as it has existed for decades.
Turns out these poor families can’t afford to pay insurance premiums, even on the income-based sliding scale from $1 to $100 per month established in Pence’s bill. A full 324,840 people failed to make at least one of these payments in the relevant period, causing most of them to lose access to affordable dentistry and eye care — and knocking several thousand off of the insurance rolls entirely.
Such high levels of drag on the Medicaid enrollment expansion in Indiana undermine many of the positive knock-on effects that come from insuring people who cannot afford their own insurance. Again, this was a predictable outcome. Policy analysts have persistently warned that turning the nation’s “insurance for people who can’t afford it” program into a “insurance for people who can kinda afford it” program would drastically reduce its reach, and thus its benefits to all members of the country’s shared economic future.
The new Indiana figures come in as Verma is positioned to approve or disapprove all states’ proposals for tinkering with Medicaid rules. Verma has recused herself from the government’s decisionmaking on state waiver proposals that she helped craft before entering Trump’s administration, including Kentucky Gov. Matt Bevin’s (R) quixotic plan to use Medicaid as a social engineering program in which enrollees earn or lose loyalty rewards from the state based on their behavior.
But she has also encouraged all states to impose Pence-style premiums for Medicaid. One of Verma’s first official acts in office was to draft a letter, sent to state leaders “hours after she was sworn in” according to the Washington Post, “urging states to alter the insurance program for the nation’s poor by imposing insurance premiums, charging them for part of emergency room bills and prodding them to get jobs.” Health and Human Services Secretary Tom Price co-wrote the letter endorsing the policy mechanisms that have cost hundreds of thousands access to full coverage in Indiana.
Conservatives often argue they did not start this war, that Obamacare’s expansion of Medicaid access to certain populations living slightly above the federal poverty line was the opening shot. States should have authority to tweak the program for this new category of beneficiaries, they say. Such families should bear some share of the costs of their care, the argument goes, and should have to do more to demonstrate they are worthy of society’s help.
But as the House GOP’s health care overhaul measure makes clear, the conservative movement would in fact like to impose such radical changes to the DNA of Medicaid for all of its recipients. That bill slashes funding to the program by almost a trillion dollars.
Nearly one in six insured Americans get their coverage through Medicaid. Such vast funding cuts to a program so central to the delicate overall architecture of the U.S. health care business are likely to set off an earthquake for all its recipients — and one that could quickly spill over into health care service options and pricing realities for other Americans.
Price has claimed that zero people will lose health insurance coverage despite the cuts, which violate one of Trump’s own campaign promises. When pressed similarly about the cuts, Trump’s budget director Mick Mulvaney promised that “everybody will have coverage that’s better than what they had under Obamacare.”
Mulvaney, Price, Verma, GOP congressional leaders, and Trump himself are not only stuck defending vast Medicaid cuts. The bill they are boosting also uses that money taken from a poor people’s program to fund a giant tax break for the richest Americans.