PLANK JUNE 21, 2012
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Now that the Supreme Court has left the fate of the Affordable Care Act hanging another few days, it seems an opportune moment to pose a question that has been growing on me after several recent reporting trips: why aren’t the most obvious beneficiaries of the law more aware of it?
There is an assumption in much national coverage of the law’s unpopularity that the right has won the “messaging war” on the law, partly, as Abby Goodnough lays out in a strong New York Times piece today, by spending far more to bash it on the airwaves than the law’s supporters have to defend it. There’s also an assumption that many in the white working class who will benefit from the law are sharply opposed to it because they, well, don’t much care for the guy who signed it into law. Both of these things are no doubt true. But my reporting leads me to think that the problem, to a large extent, gets to a very specific issue: the decision by the administration not to broadcast the part of the law that will have the most obvious, immediate impact on the working class: the expansion of Medicaid.
At least half to the expanded health coverage in the law—an estimated 16 million people—is to come through bringing Medicaid eligibility, in 2014, up to a national threshold, 133 percent of the poverty level (about $31,000 for a family of four.) The impact is going to be especially big in states of the South and West that now have exceedingly stingy eligibility rules—in Texas and Virginia, among others, earning as much as $10,000 a year disqualifies even a parent of small children from getting covered; if you’re childless, forget about it.
But when was the last time you heard the administration talking up this massively consequential part of the law? To the extent it does try to promote the law, it’s all about the filling of the donut hole for the Medicare drug benefit, letting young people stay on their parents’ insurance until age 26, credits to small businesses, and new rules on preexisting conditions. All important elements, but none as significant as the Medicaid expansion.
Well, it’s not hard to understand why the Medicaid part of the law was played down. It’s a pure expansion of the public safety net. Whereas the rest of the coverage expansion is, as Obama likes to stress, based on the private sector—by providing subsidies for people further up the income ladder to purchase private coverage—the Medicaid expansion is simply adding a lot more people to the rolls of a government insurance program (although in many states, Medicaid is contracted out to private HMOs, an increasingly lucrative sector for insurers). Moreover, emphasizing the Medicaid expansion would only draw more attention to the bewailing by governors (mostly Republican, though not all) about the burden that the expansion will add to their budgets—never mind that the cost of the expansion will be picked up almost entirely by the federal government, an outrageously good deal for the aforementioned “stingy” states that will be paying far, far less to cover the working poor in their states than the more generous states will be paying for their share of Medicaid costs.
So yes, I grasp on one level why it's been hush-hush on the Medicaid expansion. But it's also greatly disheartening to come across the consequence of this hush-hushness: people who will directly benefit from the expansion who have not a clue that it is coming. In Ohio, I met Columbus resident James Tichenor, a 50-year-old McDonald's employee without health insurance:
A van missing a wheel sat jacked up on the driveway; an armchair lay on its side in front of the house; a 16-month-old boy, the son of Tichenor’s deceased niece, cried inside the house. Bruskin forged ahead, taking it in stride when Tichenor said he had no e-mail address (“I don’t know nothing about computers”) and that he could not give any money (“Right now, I’m pretty well busted”). He told me he wasn’t sure who he was voting for. I asked: Wouldn’t Obama’s health care law help him? He shook his head, saying he couldn’t afford the $51 per week bare-bones health plan offered by McDonald’s. I told him I was pretty sure that, if his employer didn’t offer decent, affordable coverage, he would qualify for Medicaid, which Obamacare will greatly expand. He said he’d never heard anything about that: He worked nights and didn’t watch the news.
In Tennessee, I met countless people who will qualify for Medicaid but knew nothing of this, including Robin Layman, a 38-year-old mother of two who lost her Medicaid coverage last fall, the day she returned from a week in a psychiatric hospital after a suicide attempt, and hasn't been to a psychiatrist since because she can't afford it, and who is also petrified that her 18-year-old son, who is still dealing with major surgery after being hit by a speeding driver two years ago, will soon age out of Medicaid. "What new law?" she said when I told her about the Medicaid expansion. "I've not heard anything about that."
So: the next time you hear pundits talking about how voters don’t like Obamacare, keep in mind: not only are many voters getting bad information about the law, many of them are getting zero information about the law.
follow me on Twitter @AlecMacGillis
14 comments
Alec, I read the NYT article and what amazes me is how much this Administration and the Democrats have failed so miserably in pointing out what it DOES for the average American (including all of those unemployed, aging white people) who thinks that Obamacare is some sort of free handout to the urban poor and will only end in rationing healthcare. Obama and his Democratic cohorts spent the better part of a year getting ACA passed and have spent more time and energy explaining what it doesn't do. Why? Because they let the GOP and their sock-puppet PACs frame the debate. So they've been playing defense from day one. If the ACA falls under the SCOTUS axe, don't expect much support from your average person for healthcare reform for another 20 years. Meanwhile, we can watch what the GOP will have wrought upon the American public once the ACA is overturned, dismantled and otherwise crushed IF Romney is elected and GOP gains more seats.
- singlspeed
June 21, 2012 at 12:47pm
MacGillis is one smart guy. And honest to boot. I mentioned in a comment yesterday that modern medicine is great at keeping the dead alive, and asked the (rhetorical) question why. The answer, of course, is medicare and the enormous resources put into it. Yes, deep throat was right: follow the money. I then asked what would be the consequence of ACA, before whining about ACA's lack of focus on the nearly old (that would include me), allowing a 3 to 1 premium discrimination based on the age of the insured even though age, like cancer, is a chronic, pre-existing condition. Why does ACA allow discrimination against the nearly old? Because it made the cost of the Medicaid expansion MacGillis discusses much cheaper and, hence, the overall cost of ACA much cheaper. Yes, fellow baby boomers, we are helping pay the cost of ACA's main goal of universal coverage. But I digress. What will be the consequence of ACA? I'm not smart enough to know, but I do know that enterprising folks are busy organizing medicaid HMOs (maybe MacGillis would like to invest). The other thing I do know is that doctors don't like to treat medicaid patients (low reimbursement). So here's my prediction: a much more obvious dual system of health care, one for the poor (and the nearly poor added to medicaid by ACA) and the other for the rich (relatively speaking). My next question: which system will attract the highest quality doctors?
- rayward
June 21, 2012 at 12:52pm
Even people who would benefit from Medicaid hate the idea of Medicaid -- just the name represents a government "handout," taking from taxpayers (and opponents inevitably think of themselves as taxpayers, even if they're more likely to be the WSJ's "lucky duckies") to give perks to the undeserving. No one likes to say they're on Medicaid, simply because of the stigma. Obama would have done well to call the Medicaid expansion something else. MediPlus, anyone?
- ekeizer
June 21, 2012 at 3:18pm
I think the president should have hit that note "Yes, Obama cares!" much more strongly. He touched it gingerly a year or so ago, but I think it has great promise as well as being a good rhetorical weapon to confuse the Right.
- ironyroad
June 21, 2012 at 3:51pm
The NYT's article lead with the example of a 33 year old woman making less than 35K who didn't know that ACA would help her. Checking the health reform calculator on the Kaiser Foundation website we find that a single woman making 34.5K would be required to buy a $3832 policy. ACA would provide a $555 subsidy. She would pay the remaining $3276, 9.5% of her income. The policy would cover 70% of medical expenses. I'm not sure the woman in question would be jumping for joy, even if she did understand the ACA. The expansion of Medicaid may help many, but middle income people, both single and with families, will have to shoulder a significant burden.
- Vogelfam
June 21, 2012 at 3:54pm
Lead should be led in the first sentence of my post above. Sorry.
- Vogelfam
June 21, 2012 at 4:09pm
Vogelfam's example is correct (though Kaiser says the policy covers 70% of the "actuarial value", whatever that means). Think about that. This 33 year old woman pays about 10% of her income for health insurance and another 15% for social security and Medicare (for current beneficiaries) that she won't receive for another 32 years, if ever. That's 25% of her income. And she must pay 30% of the "actuarial value" of her medical expenses to boot. It's not that ACA makes this woman worse off (wouldn't a responsible person want health insurance and be better off with subsidized health insurance), it's that the nearly poor are screwed with or without ACA (though screwed a little less with ACA).
- rayward
June 21, 2012 at 4:17pm
"Now that the Supreme Court has left the fate of the Affordable Care Act hanging another few days, it seems an opportune moment to pose a question that has been growing on me after several recent reporting trips: why aren’t the most obvious beneficiaries of the law more aware of it?" The main reason is because they're lazy. They'd rather watch the Kardashians on TV for an hour than spend 15 minutes researching the ACA online. As for the folks in the Tennessee hills, they aren't going to get much information about anything. They're just not information oriented. Honorable people, most of them, but they're not inclined to be inquisitive. The survival of the ACA is important for the survival of American democracy. After food and shelter, health care is the most important matter in a person's life. If the beneficiaries of the Act don't care to learn about it, then the Act and democracy will eventually die. Freedom cannot survive without informed citizens.
- magboy47.
June 21, 2012 at 4:27pm
I think magboy pretty much sums it up right there.
- GSpinks
June 21, 2012 at 4:40pm
Relative to rayward's comment, there is very real "class" resentment between those lower class working folks who do not qualify for help, and those down the street who have subsidized housing, daycare, utilities and free healthcare. They don't see the perks of the parasitic millionaire, but they do see what is right in front of them, hence their resentment is focused down, not up.
- Vogelfam
June 21, 2012 at 6:04pm
Millions will benefit and don't care? It could be because they recognize a benefit today is a tax tomorrow. The ~$60K earner today is at a break-even with government. He pays about $6K per year in taxes, and gets about $6K/year in benefit. Those making more than $60K are at a net loss with government, and those making less than $60K are at a net win with government. But make no mistake, that $60K threshold will only go down. That is, in a few years, it is inevitable that the $50K earner will get less from government than he gives. The EU shows us the path here: In the EU, the working poor pay a crapload in taxes. In return, they get healthcare whether they wanted it or not. In the US, our working poor have a lot more disposable income than the working poor in Europe. With that extra income, they can buy a health care plan that is tailored to their needs, or they can whatever else they want. That they sometimes don't opt to buy health care insurance says they don't really see much value in the product. And 95% of the time, they will come out ahead by skipping it.
- seattleeng
June 21, 2012 at 6:36pm
seattle: "In return, they get healthcare whether they wanted it or not." Once again, one is in awe of the principle of language that says that funny things are funnier when the author didn't intend them to be funny.
- ironyroad
June 21, 2012 at 6:55pm
"In the US, our working poor have a lot more disposable income than the working poor in Europe. With that extra income, they can buy a health care plan that is tailored to their needs, or they can whatever else they want." seattle, You are astonishingly out of touch with reality. Why do you think they call them the working poor--because they have piles of loose cash sitting around the house waiting to be blown on such non-essentials as health care? You're a perfect Romney voter. An alien from Mars knows more about what's going on in the majority of households in America than you and Nitwit Mitt do. The working poor often have to buy milk for their children on credit. What spaceship did you disembark from? And, of course, almost nobody ever gets sick, so why would anybody but 5% of the population even have a use for health insurance? You remind me of the laughable Newt Gingrich, when he suggested that we all take out personal health care accounts, like we did in the Fifties. Yeah, one of those little pleated cups that your meds come in at the hospital costs $5 now. In the Fifties my mother got over a half hour in the doctor's office for $5. And she still had to get it on credit. You see, we were the working poor.
- magboy47.
June 22, 2012 at 1:40am
Seattle, a question: How much do you think is the annual cost of insurance for a working poor family of four (two parents, two kids) with a father age 42 and a mother age 36 who live in public housing in an inter city -- say Chicago or LA or NYC? What are the deductibles and co pays? What would be the cost if one of the kids has a pre-existing condition? Different question: How many US bankruptcies each year are because of medical bills? Different question: How many dollars are misspent because of lack of preventive care and use of emergency rooms for relatively routine care?
- PeteBeck
June 22, 2012 at 10:19am