While the bills thus far included useful health measures — including $4 billion for the Centers for Disease Control and Prevention, insurance coverage with no cost-sharing for testing for the coronavirus (though not treatment), and $100 billion for hospitals — critical omissions remain. The most salient is the failure to expand health coverage. Given that most working-age Americans and their families get health coverage through work (58 percent, pre-virus), in a period of massive layoffs, this omission must be corrected.
The intersection of a health and economic crisis is particularly dangerous for low-income families with few resources to fall back on should they get sick. Fortunately, the expansion of Medicaid through the Affordable Care Act will significantly reduce this risk for such families, in states that took the expansion. Low-income families in states that have either not signed on to the expansion or have done so in ways that depress enrollment face real hardship that could be mitigated by forthcoming legislation.
Unfortunately, politics is very much in this mix. Though this has gotten lost in the fray, the Trump administration is still pursuing its lawsuit to strike down the ACA. Should it prevail, this would of course end the Medicaid expansion but also the premium subsidies in the exchanges, making it that much more expensive for families to get re-covered if they’ve lost their employer-based coverage.
Republican governors in states long hostile to the ACA continue to throw up coverage roadblocks. Following a successful grass-roots effort to expand Medicaid in Oklahoma, and in a period of unprecedented layoffs, Gov. Kevin Stitt (R) requested a waiver that would withhold coverage to those who don’t meet a work requirement — even though, as policy analyst Jesse Cross-Call writes, “federal courts have repeatedly struck down similar waivers in other states.” Cross-Call reports similar barriers to Medicaid expansion in Kansas and Nebraska, actions that will result in millions of low-income adults being uninsured throughout this crisis.
Still, the ACA remains the law of the land, and some displaced workers should be able to get help through subsidized coverage in the marketplace exchanges. Many are blocked from this solution, however, because the Trump administration has thus far refused to enact a special enrollment period, in part because it doesn’t seem to know how the law works. Trump officials claim that step is unnecessary because job losers can enter the exchange marketplace at any time — but this is only true if the job they lost provided health coverage. As health policy expert Tara Straw explains, this does not apply to many lower-income workers, whose compensation does not include health insurance benefits. They require a special enrollment period.
If you’re thinking all of this seems too complicated for families struggling with survival in the midst of this crisis, you’re right. There are two steps that should be forthcoming, one near-term and the other long-term.
In the near term, forthcoming phases of relief legislation should expand access to coverage through Medicaid and the ACA exchanges. Medicaid has a long history of ramping up in response to downturns, but this “countercyclical” dynamic is twice as powerful in ACA expansion states. The next package should have the federal government temporarily covering the full cost of expansion, up from the current 90 percent, along with a higher federal match rate for regular Medicaid (which is financed jointly by states and the feds). For those with higher incomes seeking coverage on the health-care exchanges, we must make their coverage affordable by increasing the premium tax credits, thereby lowering the out-of-pocket costs for people who just lost their paychecks.
For the longer term, the crisis is revealing two essential insights that many of us have been trying to elevate for a long time. First, the way we run health care in this country is in need of major reform, and a key focus of that reform must recognize health care as a right, not a market-driven commodity. Second, this is an area where politics is a matter of life and death.
Ours is the only advanced economy that maintains such close ties between health care and employment, while failing to regulate prices, affordability and access to coverage. We notoriously spend far more on health care with worse outcomes. We’ve slogged along for decades at this unfortunate place, with the deep-pocketed health-care lobby funding its conservative political allies to fend off any revisions that threaten clients’ profits.
In a crisis like this one, the downsides of the status quo flare up in particularly frightening ways as we try to rapidly implement complex measures to tide us over. We should — we must — have this fight, on behalf of the millions of people facing potential hardship, illness and even death. But we also must come out of this crisis with even more resolve to start down the path toward affordable, inclusive, universal coverage.