The future of the Affordable Care Act remains uncertain at this writing. ACA proponents can boast of many accomplishments. It has reduced the ranks of the uninsured by 20 million. It has improved quality and safety of American medical care and reduced financial distress associated with medical bills. Yet for all its accomplishments, the ACA did not fully address one reality that neither Democrats nor Republicans fully acknowledge: Coverage remains too costly for many low-income workers. Until we address this reality, millions of people will remain uninsured, and many millions more will have reason to resent a health care financing system that fails to meet their needs.
I was reminded of this reality reading a prominent Washington Post story about a 59-year-old Texas woman named Tamara Estes. Ms. Estes lives paycheck to paycheck on her $24,000 annual income as a part-time school bus driver. She is uninsured. I looked up Ms. Estes’ available options under ACA. She is apparently eligible for a silver plan with a monthly premium of only $69.44. If Republicans repeal ACA, she would have to pay much more.
But that’s only part of the story. Ms. Estes has fairly good reasons to feel disappointed by the ACA. It’s true that the ACA would provide her with a $578 monthly subsidy. But that $69.44 monthly premium brings a $2,250 deductible, and she would be vulnerable to out-of-pocket costs that could exceed $5,000. This is a person with $118 in the bank, with four days to go until payday. If she can in any way avoid this, she’s not going to seek medical care.
The fact is: ACA doesn’t do enough for working people like Tamara Estes who earn too much to receive Medicaid, yet still struggle to afford their health care. That’s ACA’s original sin, for which conservative Democrats, fiscal hawks, and Republicans bear responsibility.
The contrast with ACA’s Medicaid expansion is striking. It’s surprisingly popular among Democratic and Republican recipients who have gained coverage. Of course, Medicaid has major shortcomings, most ultimately rooted in the low rates with which Medicaid pays doctors and hospitals. Yet Medicaid brings the offsetting virtues of simplicity. Care is typically free, without the crushing deductibles and copayments private coverage often brings. Although establishing and maintaining Medicaid eligibility can be burdensome, recipients encounter less paperwork and arcane rules in actually seeking care.
Medicaid expansion commands surprisingly broad bipartisan political support. House Republicans would dearly love to cut or eliminate ACA’s Medicaid expansion. They are discovering few allies in this effort. Doctors, hospitals, the AARP, and many others oppose them. More surprising is the deep opposition among Republican governors. These governors have spent billions of dollars to own their Medicaid expansion and to make it work. They don’t want this work undone.
Many are proud of what they have accomplished, for example, to expand addiction treatment. Since 2010, many Republican governors, including Michael Pence and John Kasich, negotiated effectively, often quietly, with the Obama administration to find a politically dignified path to their preferred form of expanded coverage. I suspect many Democratic governors will do the same with President Trump. No one will be completely satisfied. Medicaid will look different in Indiana than it does in Massachusetts or New York. That’s what bipartisan state-federal health policymaking actually looks like.
ACA’s marketplaces have never generated that same bipartisanship. Their market-based structure is more congenial to Republican ideology. Yet few Republican politicians feel pride of ownership in this centerpiece of Obamacare. When consumers such as Ms. Estes encounter difficulties, these politicians have proved unwilling to support measures to sweeten existing subsidies or to stabilize marketplace premiums through various technical programs to compensate insurers who serve risky consumers.
No one knows how the current legislative battle will be resolved. No one really knows what will happen to ACA’s state marketplaces, which will likely remain stable but smaller and more fragile than their original backers hoped or expected them to be.
Maybe Medicaid has something better to offer Ms. Estes and others, whose access to care was improved but never fully secured by the ACA. Working poor people don’t want a system with $2,250 deductibles, and they may never use it well. They prefer a system that controls costs in other ways, even if the resulting care is a bit more gritty. Medicaid expansion offers a politically durable and humane path to expand coverage, improve population health, and improve financial security.
Harold Pollack is the Helen Ross Professor at the School of Social Service Administration.