Some good news

 North Carolina took a giant step today in the right direction. Their state legislature finalized a bill to expand Medicaid under the Affordable Care Act (ACA) to otherwise ineligible people earning up to 138 percent of the federal poverty level. It is estimated that this will benefit around 600,000 people.

But it's not just about health coverage. The expansion will bring in millions of federal dollars, create jobs, keep rural hospitals open, help people recover from Substance Use Disorder and all kinds of other good stuff.

By my count--and counting has never been my strong suit--North Carolina is the 41st state, including DC, to take this step. It's especially important that this happened in a southern state. Let's just say that if one was drawing a Venn diagram of states that resisted expansion with states that belonged to the Confederacy there is considerable overlap. At the risk of extreme understatement, this might not be entirely coincidental. But every time this happens, it puts more pressure on the holdouts to do the right thing.

A little review: Medicaid expansion was intended for all states and DC when the ACA was passed in 2010. A 2012 US Supreme Court decision upheld the constitutionality of it, but made expansion a state decision. Depending on the state, the decision could be made by ballot measure, executive decision, or legislation, which is always more complicated.

We were lucky that West Virginia's decision was made before the state turned into a ________ (you can fill in the blank) by my favorite all time governor, Earl Ray Tomblin. The state agency in charge did a fantastic job of signing people up. Lots of people I know worked really hard to make sure that happened. I'm not sure of the current enrollment numbers, but at times it has come close to 200,000 adults in a state with a population of 1.8 million, more or less.

However, we had to spend a lot of years defending it, especially during the Orange Epoch, when the late Senator John McCain, to his great credit, stopped efforts to repeal it in the senate. West Virginia was in the hot seat then too, with a conservative Democrat and a fairly moderate Republican in the persons of Joe Manchin and Shelley Moore Capito. Manchin took a "fix not nix" approach and Capito said that she "didn't go to Washington to hurt people."

Then there were state legislative efforts by out of state groups like ALEC and the Foundation for Government Accountability to impose bureaucratic hoops and reporting requirements designed to cut people off as recent as this year, which were fortunately defeated. It also was a huge relief when the US Supreme Court (!) effectively squelched efforts to undo the law in 2021.

I imagine folks in North Carolina will have to be vigilant on the enrollment process and ready to defend the expansion when efforts are made to weaken it. But it's still a great day.

Next stop...maybe Alabama? Sometimes the domino theory has its moments.

Good news on health care

 It’s not obvious from the title, but the recently passed Inflation Reduction Act (IRA) is the biggest federal health care legislation in a dozen years, one that will directly benefit over one in four West Virginians.

For starters, the law permanently extends the Black Lung Excise Tax, which provides benefits for over 4,400 West Virginia families impacted by that terrible disease caused by breathing coal dust. Nationwide nearly 26,000 families will benefit, including over 18,000 primary beneficiaries and around 7,000 dependents. According to the Brookings Institution, Black Lung is most prevalent in central Appalachia, with 20.6 percent of miners affected. 

In the late 1960s, a historic grassroots movement spearheaded by West Virginia coal miners and supporters brought the issue to national attention and won federal legislation to establish the benefit, although its funding was in jeopardy in recent years until the bill was passed.

The IRA also extends Affordable Care Act (ACA) marketplace subsidies for three years for people who purchase insurance plans on the exchange, which will help around 23,000 West Virginians and over 14 million people nationwide.  

People who buy care through the ACA marketplace have traditionally been the hardest group to find health care since they aren’t covered by employer-based insurance and don’t qualify for public programs such as Medicare, Medicaid, Tri-Care, or VA benefits. Thanks largely to ACA subsidies and Medicaid expansion, the number of uninsured Americans reached an all time low of eight percent this summer: still too high but a big improvement.

The biggest impact of the bill will be on people receiving Medicare, which covers over 440,000 West Virginians and around 64 million Americans, although these changes will be rolled out over time. 

According to the Kaiser Family Foundation, in 2023 insulin will be capped at $35 a month on the Medicare Part D prescription drug program; drug companies have to offer rebates if prices increase above inflation; and cost sharing for adult vaccines under Part D and Medicaid will be eliminated.

The Medicare diabetes cap is a big deal, although a ruling by the senate parliamentarian blocked its application to private insurance. According to the American Academy of Family Physicians, which supported several IRA medical provisions, “More than 37 million Americans have diabetes, and an estimated one-quarter of people with diabetes in the United States ration their insulin due to costs. In 2021, U.S. diabetes deaths exceeded 100,000 for the second consecutive year.” The WV Department of Health and Human Resources estimates that 240,626 West Virginians have that disease with undiagnosed cases 65,210.

In 2024, the IRA caps Medicare premium increases to six percent a year through 2030; eliminates a part D co-pay for catastrophic coverage; and expands eligibility for the low-income Part D subsidy to 150 percent of the federal poverty level. In 2025, it caps drug costs for Medicare beneficiaries at $2,000 per year. And between 2026 and 2029, it will negotiate costs for an increasing number of expensive medicines each year.

While health care is only part of the IRA, which also addresses climate change and tax fairness, those are significant steps in the right direction and Senator Manchin was instrumental in sealing the deal. Of course, no legislation is perfect. Lots of West Virginians, myself included, worked hard on what would become the IRA for the last year or so. We didn’t get all we wanted and got some of what we didn’t, but there are still things to celebrate.

(This ran as an op-ed in the Charleston Gazette Mail last week.)

Good news if the deal is sealed

 By now, I'm guessing most interested people have heard of the deal reportedly struck by Senators Schumer and Manchin on climate, prescription drugs, and health care. It was quite a reversal of fortune from the last two weeks.

Here's a brief statement in response penned by yours truly and AFSC DC colleague Peniel Ibe about the deal on Twitter:

Me:

Over the last year, many West Virginians worked hard to push a reconciliation bill across the line. While the outlines of the potential deal are not as bold as many hoped in addressing family economic security, we are optimistic and relieved to learn that an agreement on addressing climate change is within reach and appreciate protections for health care.  

Certain provisions in this bill will have tremendous benefits for the children and families in the Mountain State. Looking forward, we will continue to work with the Senator to ensure that components not included in the package, such as the Child Tax Credit, are enacted to provide even more support for West Virginia’s families and children.  

Peniel:

The existence of this bill is a testament to the commitment for advocates across the country to delivering much needed relief for our communities.  

The wins are hard fought, delivering on provisions to lower health care costs, reduce the deficit, tax wealthy corporations, and invest in some clean energy projects and the environment.  

But the losses are just as painful. As negotiations stalled, critical investments included in the initial package were cut, sacrificial compromises were made, and countless people lost out. The bill currently includes some counterproductive provisions that further entrench the use of fossil fuels into our society- disregarding the intensity of the climate crisis and calls from front line communities.  

Yet this plan to begin to address the needs in our communities’ wellbeing is still at risk of being cut to a point beyond meaningful impact. We call on all Senators to focus on delivering relief now as there is more to do. We have waited too long and we must no longer leave our communities needs unaddressed.  

Today, many people across the U.S. struggle to make ends meet—especially amid soaring costs of housing, groceries, and other goods. We must continue to call for massive investments in a robust care infrastructure, including monthly Child Tax Credit payments, paid family/medical leave, closing the Medicaid coverage gap and more. 

This is the only way to build vibrant communities. 

I'm still nervous and will be until the deal is actually sealed, but this was welcome news in tough times. 

 

Not all bad

 Whenever there's a bit of good news on the economic justice front, admittedly not an everyday occurrence, I try to notice it. Here's the latest:

According to the Centers for Medicare and Medicaid Services (CMS for short) a record number of Americans now receive health insurance through the Affordable Care Act (ACA)...and what a fight it was to enact and protect it all these years. Specifically, more than 35 million people are either covered through the health exchange or marketplace, expanded Medicaid (21 million in states that expanded Medicaid as WV did in 2013), or basic coverage.

That's more than one out of ten Americans in a total population of around 332+ million. It's an even bigger achievement when we factor in who got that coverage. The US health care system does a pretty good job of covering the elderly via Medicare. Close to 95 percent of children are covered via CHIP, traditional Medicaid or their parents' insurance. Low income people with disabilities are likewise often covered by traditional Medicaid. Those covered by the ACA, on the other hand, are working age adults not eligible for other kinds of insurance--and those most likely to lack coverage before the ACA. 

The percent of uninsured Americans is now at an all time low of around 8.8 percent. Still too many by far, but it shows the benefits of this signature legislation of the Obama administration. And a lot of people in West Virginia worked hard to make that happen here. I hope the 12 holdout states--Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming--see the light and expand Medicaid soon (did anyone else notice that eight of those were also part of the Confederacy?). I know lots of people in those states are working on it. 

This may not last forever the way things are going, but I'll celebrate this for now anyway.

Signed. Sealed. Delivered. For real

Whew. It's been a long fight, but the US Supreme Court announced today that it would not overturn the Affordable Care Act. As the New York Times reports,

Striking down the Affordable Care Act would have expanded the ranks of the uninsured in the United States by about 21 million people — a nearly 70 percent increase — according to recent estimates from the Urban Institute.

The biggest loss of coverage would have been among low-income adults who became eligible for Medicaid under the law after most expanded the program to include them. But millions of Americans would also have lost private insurance, including young adults whom the law allowed to stay on their parents’ plans until they turned 26 and families whose income was modest enough to qualify for subsidies that help pay their monthly premiums.

A ruling against the law would also have doomed its protections for Americans with past or current health problems — or pre-existing conditions. The protections bar insurers from denying them coverage or charging them more for it.

This is a big deal for me as I've put a lot of time in on this over the last 12 years, including street actions in support of its passage; bus rides to DC: probably dozens of op-eds; scary town hall meetings, including one where an ACA opponent heckled a priest during an opening prayer; pushing for Medicaid expansion in WV and other states; fighting off attempts to mess with Medicaid expansion; mobilizing to defend it in various ways after Trump's election; urging WV's senators not to undo it when that was a real option; and more. You can probably find scores of posts about it here. I'm also proud that the American Friends Service Committee was part of this effort from the beginning.

I'm hoping this settles things once and for all and that we can keep building out and expanding care, including expanding Medicaid in the twelve holdout states. It's probably no coincidence that eight of those states were part of the Confederacy during the Civil War. As I wrote here in 2014, there's a long and ugly connection between the legacy of racism and denying health care to millions of Americans of all backgrounds. I'm hoping this is a nail in that coffin.

Happy 11th birthday, ACA!

It's been a bumpy 11 years since the passage of the Affordable Care Act, and there have been times I was afraid for its survival, but it's still here, thanks in no small part to the efforts of millions of people all over the place to enact and protect it. Now, we're even improving it, at least temporarily, thanks to the American Rescue Plan Act.

I know I've done this before, but I can't resist reposting this item from the day after it was signed into law in 2010, with comments from today following. To quote Dylan, "lotta water under the bridge/lotta other stuff too."

 It's official. President Obama signed the health care reform bill into law yesterday.

He told those in attendance that "We have just now enshrined, as soon as I sign this bill, the core principle that everybody should have some basic security when it comes to their health care."

Critics of the bill may point out that this isn't exactly the case, but there's no denying that this is a landmark piece of legislation that will extend health coverage to millions who have been doing without it. The New York Times calls it "the federal government’s biggest attack on economic inequality since inequality began rising more than three decades ago."

It remains to be seen whether the immediate benefits (political and otherwise) will outweigh the blowback. This item from Politico argues that the former will come before the latter, but I'm not sure I agree. It always seemed to me that a major drawback of the legislation was that the major expansion of health coverage via Medicaid and subsidies won't hit until several years down the line, meaning that the risks might hit earlier than the benefits.

Still, it probably will be hard for those who want to repeal it to win much of a crowd by saying "Bring back the donut hole" for Medicare Part D, or "let's cut those young people off their parent's insurance" or "Bring back denials of coverage for pre-existing conditions!"

The game has changed, although it's hard to guess just how or how much.

Looking at the post from 2021, I'd stand by it. I've never been big on making predictions, but I think I was right in worrying that the negative consequences, political and otherwise, would hit first, long before the benefits became apparent. Eventually the positives were felt, but not before a lot of political damage was done. And that the game really had changed.

I'd prefer not to go through all that again, however.

 

 

The politics of health care in a pandemic

In a recent post about health care, I suggested that Oklahoma's ballot measure on Medicaid expansion would be one to watch. Well, sure enough, voters in that heavily Republican state approved the measure by a little over 50 percent. Considering the dark money that went into opposing it, I'd call that a landslide. Dollars seem to count more than votes most days.

Interestingly, Oklahoma was the first state to expand Medicaid during the COVID-19 pandemic. But it may not be the last. Missouri is scheduled to vote on the measure August 4. And so far, expansion has passed in every state where it was put on the ballot.

As I've argued many times before, it's good news any time a state takes advantage of this best provision of the Affordable Care Act. First, it improves and saves lives. Second, it creates jobs and generates a lot of economic activity. Third, it helps more people stay in the workforce. Fourth, each expansion makes it a bit harder to get rid of the whole thing.

Back to Oklahoma. This is also the state that took up the Trump administration's horrible idea of accepting a cap on Medicaid spending. Looks like that ain't gonna happen.

This article from Politico argues that the pandemic has upended the Trump/Republican dream of rolling back health care. I don't know if that's true, since the US Supreme Court could still do a lot of damage.

Still, I think we can agree that the optics, in the parlance of our time, of taking health care away from people or keeping them from getting it to start with just don't look that good. In an election year.

We'll see. But this is another reminder that all news isn't bad.

One to watch

If you care about the future of health care, pay attention to tomorrow's election in Oklahoma, where Medicaid expansion is on the ballot. This would be the first state to consider expansion since the COVID-19 pandemic took off. If it passes, it could bring health care to around 200,000 adults.
Needless to say, there's a lot of dark money opposing the measure.

According to the Kaiser Family Fund, 37 states (including DC) have adopted the expansion. In general, I think every state that expands the program makes it a little bit harder to undo the whole thing.

Medicaid expansion has been a huge benefit to West Virginia, bringing in billions of dollars, supporting thousands of jobs and providing coverage to around 200,000 low income adults in any given year. At any given point lately around 160,000 are covered by it.

This vote takes place in the shadow of an impending US Supreme Court decision on the constitutionality of the Affordable Care Act. Overturning it and taking away health care from millions of Americans seems to be a priority of both the Trump administration and WV Attorney General Patrick Morrisey, (which makes me want to reread the first volume of Dante's Divine Comedy to see which circle that would qualify one for).

Doing the math: what repealing the Affordable Care Act would mean for WV

At the risk of being a downer, I feel the need to point out what’s at stake for West Virginia in the latest effort on the part of the president (and the state attorney general) to kill the Affordable Care Act in court.

Spoiler: a lot.

Let’s start with recovery from addiction and mental health. Back in 2017, state officials said that the ACA, and particularly Medicaid expansion, helped bring treatment for addiction to 50,000 West Virginians. That number has no doubt gone up since then.

Recently, Lori Kersey reported in the Gazette-Mail that low-income West Virginians got $90 million worth of mental health and substance abuse treatment last year and almost $300 million over the last four years.

She cited data from the state Department of Health and Human Resources that the state’s expanded Medicaid program provided around $58 million in mental health and substance abuse treatment in 2015. It increased to $61 million in 2016, $79 million in 2017 and $90 million in 2018.

I’ve talked with people who are convinced that access to that treatment saved them from death or worse and brought them back to the land of the living. Now they’re clean, putting their lives together, taking care of their children, holding down jobs and paying taxes.

As Jesus said in one of his most famous parables, “be glad for this, your brother was dead, and is alive again. He was lost and is found.” (Luke: 15:32)

Now imagine all that gone.

Then there’s this: According to the DHHR, as of April 1 of this year, 160,356 West Virginians were covered by Medicaid expansion, a state option under the ACA. Most of these people are holding down jobs. Another 22,600 state residents bought coverage under the ACA exchange. Then there are around 12,000 young people in the state who can stay on their parent’s insurance until age 26, another ACA provision.

Then there’s the fact that the ACA helped reduce prescription drug “donut hole” costs under Medicare Part D for the approximately 240,170 West Virginia seniors who participate in the program. The icing on the cake is the fact that the ACA brings hundreds of millions of dollars to our economy, creating thousands of jobs and helping to keep rural hospitals and health care providers going.


The Urban Institute has estimated that repealing the ACA could result in the loss of 16,000 jobs and $9.1 billion in state economic impact.

Imagine all those dollars and jobs, too.

Then remember that those are just the numbers, but behind the numbers are real people, families and friends, people we know, work with and love.

Screwing over that many people of all ages with one stroke would be quite an accomplishment, even by today’s standards.

It would be the next worst thing to a natural disaster of biblical proportions, except the harm would be caused by the deliberate action of a handful of people.

If it comes to that, I don’t think it will be forgotten anytime soon.

(This appeared as an op-ed in today's Gazette-Mail.)

A close one

According to The Hill, WV Congresswoman Shelley Moore Capito, who has previously supported retaining Medicaid expansion, is now open to phasing it out. This would be a disaster to the Mountain State, where 175,000 people have gained coverage. According to WV DHHR Secretary Bill Crouch, that includes 50,000 people getting treatment for opioid addiction in a state that leads the nation in overdose deaths.

The House plan, according to the CBO, would over time cut Medicaid coverage for 14 million people. Even a kinder, gentler, slower Senate phaseout could end coverage for millions.

Just another reason why it's important for West Virginians to contact Senator Capito's office and urge her to preserve this lifeline for so many West Virginians. To find out how to do that, click here.

How bout that?

I must say I was surprised by today's Supreme Court decision (see yesterday's post here). I am a little concerned about the Medicaid part of the decision, in which the court said the expansion was constitutional but the feds couldn't withhold Medicaid funding from states that refuse to enroll more people. This could give states the ability to weasel out of what to me is a key piece of reform.

In other words, Medicaid expansion is the real public option.

Still and all, pretty cool.