When the Affordable Care Act passed in 2010, I was working as a legal services lawyer in Manhattan. As part of my job, I attended a monthly meeting of healthcare advocates from across the five boroughs and Long Island. Our clients were white and African American, Haitian and Salvadoran refugees, infants, middle-aged workers, teenagers with disabilities. Some were on Medicaid, Medicare, or skimpy employer-provided plans, but many had no insurance at all — too poor to buy their own but too “rich” for Medicaid.
The “coverage gap,” for those who fell in it, was a bottomless gulch. Regular, preventive doctor’s visits were unheard of, care for teeth and eyes an unimaginable luxury. Emergency rooms, which, under federal law, must treat everyone coming through, became clinics of first and last resort. Our uninsured clients were discharged with thousands, even tens of thousands of dollars in bills. I spent hours on the phone with back offices and debt collectors, negotiating discounts, payment plans, and the occasional write-off. It was a uniquely American affair.
When President Obama entered office with promises of far-reaching health reform, my colleagues and I felt skeptical but encouraged. The ACA, though hamstrung by political compromise, a catastrophic website launch, and a court ruling that let states opt out of Medicaid expansion, brought immediate benefits to poor and low-income New Yorkers. More poor people qualified for Medicaid, and those just above that threshold could buy subsidized insurance.
Over the past few months, as Republicans in the House and then the Senate tried to undo the ACA, they threatened to do much more than take us back to 2009. Up to 32 million Americans, or 10 percent of the population, were at risk of losing coverage over the next decade — mostly through savage contractions of Medicaid, the public health insurance system for the poor. The bill passed by the House in May supposedly took aim at rising insurance costs, but its main effect would be to shred Medicaid, not just by eliminating its expansion under the ACA, but by converting the program from a federal entitlement to a lump-sum “block grant” that states could use as they saw fit. When the Senate took its turn earlier this month, it proposed legislation even more destructive to Medicaid — and that, like its companion in the House, would have left more than 20 million Americans uninsured. That bill did not pass; nor did it die for good.
This week, Senate Majority Leader Mitch McConnell pushed three more times to repeal and/or replace Obamacare. First was a failed revote on the original Senate bill; next, a failed repeal without a replacement. Then, on Thursday night — coincidentally, the eve of the 52nd anniversary of the Senate’s passage of Medicaid and Medicare — came an ambush “skinny repeal” that would have eliminated the individual insurance mandate and the requirement that businesses offer coverage. The goal of that skeletal legislation was to pass something, anything, that would let GOP senators negotiate with their counterparts in the House, behind closed doors.
The skinny repeal failed, 49 votes to 51, just before 2 a.m. Friday. And though Medicaid cuts weren’t explicitly part of that bill, they had already inspired thousands of people to clog congressional phone lines and occupy House and Senate offices all over the country. Outside McConnell’s office last week, Capitol Police arrested 43 disability-rights protesters, peeling some from their wheelchairs. Activist Laura Halvorson brandished a large sign reading, “Medicaid: LIFE + LIBERTY 4 Disabled Americans.”
As New Yorkers, we may feel somewhat insulated from these currents. Our relatively wealthy, progressive state has always funded Medicaid (a joint federal-state program) more generously than most — covering single adults, elders receiving home care, certain groups of immigrants, and families just above the federal poverty level.
Yet here, too, the ACA is now the weft and warp of our healthcare quilt: At last count, one-tenth of the 6 million New Yorkers on Medicaid came through Obamacare, and nearly a million others get their insurance through the ACA-created marketplace. Winnie da Silva, a freelance management consultant, buys insurance for herself, her husband, and her three children on the exchange. “We were always dealing with premiums going up, before Obamacare,” she says. “I don’t know what our options will be if they get rid of it.”
The ACA’s passage led to a 50 percent drop in New York’s insurance premiums for individual plans; the Senate’s original repeal-and-replace plan would have cost the state $40 billion in federal Medicaid funds over the next decade.
“The number of people whom we have to tell, ‘You have no options to be insured,’ is so much lower than it was before,” says attorney Rebecca Antar Novick, who assists clients with medical debt and other health-law issues at the Legal Aid Society. “Medicaid expansion has allowed the working poor to have insurance.”
And the program’s growth under the ACA has been a boon to hospitals and safety net providers, as well. Should Obamacare be unwound, New York City’s Health and Hospitals, the largest provider of services to Medicaid patients, would lose well over $500 million per year. Private hospitals, too, would face financial ruin. “We will be a major net loser,” says Dr. Ken Davis, president of the seven-hospital Mount Sinai Health System.
The cost of a shrunken Medicaid system can be seen in Texas, where then-governor Rick Perry, who called Obamacare an “Orwellian” “power grab,” rejected some $8 billion in federal funds, leaving 2 million potentially Medicaid-eligible Texans without insurance, and hospital systems in the red. (Earlier this month, the Texas Hospital Association warned that, under the originally proposed Senate repeal, even “more Texans will be forced to rely on hospital emergency departments for care.”) This explains why eleven other Republican-led states eventually agreed to augment Medicaid, and why their otherwise conservative governors have protested House and Senate moves to cut the program.
The national backlash against repeal-and-replace is “a really big story about people power,” says Elisabeth Benjamin, vice president of health initiatives at New York’s Community Service Society. “People are coming forward and saying, ‘I’m a working person, and I’m on Medicaid.’ ‘I’m in a nursing home, and I’m on Medicaid.’ ” Their stories are all over the internet. Brian Klein, a Pennsylvanian who’d relied on free clinics for nearly a decade prior to the ACA, survived colon cancer with the help of Medicaid. Bailey Hendricks, a single mother in West Virginia, was finally able to obtain treatment for opioid addiction.
Obamacare and Medicaid may be safe for the moment, but President Trump and House and Senate Republicans are likely to propose new bills after the summer recess. Until now, “Medicare for All” has been the slogan of single-payer healthcare advocates on the left, a savvy invocation of middle-class values. It may be, however, that Obamacare has begun to redeem Medicaid, by sweeping away its associations with welfare and the “undeserving poor.” Perhaps the congressional GOP has inadvertently provoked a future rallying cry: “Medicaid for All.”