Medicaid cuts...people will die

Eight years ago, when the Affordable Care Act (ACA) was up for repeal, then-Governor Jim Justice and Senator Capito helped walk the nation back from the brink.

 Justice described the consequences of undoing Medicaid expansion, which covered around 175,000 West Virginians at the time, as “beyond catastrophic.” Capito said that “I have serious concerns about how we continue to provide affordable care to those who have benefitted from West Virginia’s decision to expand Medicaid, especially in light of the growing opioid crisis.”

They were right then and still are today.

Recently, public health experts from Yale University and the University of Pennsylvania calculated the butcher’s bill that would happen if the House version of the budget bill passes as is and it’s pretty awful. They estimate that proposed Medicaid cuts could cause 51,000 premature deaths per year, just to pay for tax cuts for the rich.

That’s more than the combined populations of Calhoun, Tucker, Gilmer, Pleasants, Doddridge, Pocahontas, and Clay counties. Or several thousand more than the populations of either Charleston or Huntington. 

According to the Yale School of Public Health, “The researchers estimate that 42,500 lives could be lost each year from disenrollments in Medicaid and Marketplace coverage and the rollback of nursing home staffing rules. An additional 8,811 deaths are projected from the expiration of the enhanced Affordable Care Act (ACA) Premium Tax Credits, bringing the total to more than 51,000.

To be specific, 7.7 million people would lose Medicaid or ACA marketplace coverage, with a loss of an estimated 11,300 deaths per year. 

Eliminating the Medicare Savings Program would disenroll 1.38 million seniors, at a cost of 18,200 deaths per year. 

Ending nursing home staffing rules could cost 13,000 lives. 

Ending ACA premium tax credits is likely to push another 5 million off, at a cost of over 8,800 preventable deaths a year. 

In addition, the bill’s failure to extend the ACA’s enhanced premium tax credits is expected to push another 5 million Americans into uninsurance, resulting in 8,811 more deaths each year.

This isn’t a matter of random number generation. According to Yale, researchers relied on peer-reviewed studies that “quantifying the relationship between insurance coverage, access to prescription drug subsidies, and nursing home staffing levels with all-cause mortality.” This data was then applied to projections released in May by the nonpartisan Congressional Budget Office.

Recently, Iowa Representative Joni Ernst stirred up controversy by dismissing concerns like these, saying “we are all going to die.”

Maybe so. But working class people don’t have to die prematurely in the tens of thousands every year just to enrich the wealthiest. 

This is totally preventable.

(This appeared as an op-ed in the Charleston Gazette-Mail.)

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.)

WV Climate Alliance on Inflation Reduction Act: "A good first step"

The WV Climate Alliance is composed of representatives of more than 20 state organizations (including AFSC) concerned about  the threat of climate change. The group released this statement to coincide with the signing of the bill into law.

Charleston, WV: The WV Climate Alliance has come together to release a joint statement in support of the Inflation Reduction Act as a “Good First Step”. Passage by the House Friday puts this historic legislation on president Biden’s desk for his signature. This legislation will now begin to move our nation forward in addressing our ever escalating Climate Crisis.

“We’d like to recognize Senator Manchin’s leadership for co-sponsoring this legislation,” said Gary Zuckett, Executive Director of WV Citizen Action Group, “and for his efforts to advance these reforms even in the face of total Republican opposition, outright lies broadcast 24-7 by dark money groups over social and regular media, and intense lobbying from Big Pharma, oil companies and other corporate special interests. In these tough times, West Virginians have been waiting long enough for these common-sense improvements.” 

"Once enacted, the Inflation Reduction Act of 2022 will help more West Virginians take control of where their energy comes from at a time when it’s needed most,” said Leah Barbor, West Virginia Program Director, Solar United Neighbors. “These clean energy investments will put us on track to reduce emissions, reduce energy bills, create good jobs and improve equity by expanding the opportunities to bring the benefits of solar to all West Virginians.”

“We want to thank Senator Manchin for ensuring the IRA passage. The IRA is truly a historical step forward,” said Lead West Virginia Veteran and Climate Justice Organizer Lakiesha Lloyd with Common Defense. “However, we must recognize that there is still much to do. We have a long way to go to ensure a renewable energy future where West Virginia veterans will not only survive but thrive. Thus, we’ll keep organizing–this bill is the step we need on our path to full climate justice.”  

“The Inflation Reduction Act is a once-in-a-lifetime opportunity to invest in climate solutions that will help protect West Virginia from the impacts of the climate crisis for generations to come. The WV Environmental Council (WVEC) thanks Senator Manchin for supporting this legislation. West Virginia now has a chance to fight climate change, create jobs and be a part of a clean energy future. WVEC is committed to continuing our advocacy for solutions that promote environmental protection across the state and advance environmental justice,” said Linda Frame, President of the West Virginia Environmental Council.

“We thank Senator Manchin for his support and leadership on the Inflation Reduction Act,” said Lucia Valentine, West Virginia Organizer of Moms Clean Air Force. “This historic investment in our future comes at a crucial time in Appalachia, as devastating floods remind us of the urgency to act for the safety of our children and for future generations. The Inflation Reduction Act puts us on a path to a cleaner, safer, and healthier future.”

“This legislation includes a permanent extension of the Black Lung Excise Tax – an unprecedented investment in the Black Lung Disability Trust Fund. This is a huge victory for every miner and mining family that is worried about how to pay for their bills and medication in light of the uncertainty around the Black Lung Disability Trust Fund. In West Virginia alone, 4,423 miners and their families are currently receiving federal black lung compensation. The Black Lung Disability Trust Fund provided $38 million in black lung compensation to West Virginia miners in 2021, or nearly 25% of the total funds disbursed nationally,” said Dana Kuhnline, Campaign Director for ReImagine Appalachia.

“The Inflation Reduction Act is an important measure towards ensuring the livability of our planet.  For West Virginians who have been fighting for just transitions, economic diversity, and growth, we believe this to be a giant step in the right direction”, stated Kathy Ferguson, Interim Executive Director with Our Future West Virginia. “However, we must acknowledge the trade-offs and we lament that the MVP will be bolstered at the expense of the IRA passage.  We will certainly keep pushing for Sen. Manchin to go further in ensuring that people are prioritized over profits and that all our communities are protected and environmentally sound.”

“The passage of the Inflation Reduction Act puts our nation on the pathway toward unprecedented greenhouse gas emissions reduction,” said Autumn Crowe, Program Director of the West Virginia Rivers Coalition. “While we celebrate this milestone, our work is not done. We recognize that some provisions within the IRA call for additional fossil fuel development which perpetuates the harm to frontline communities. We will continue to advocate for healthy communities and work toward 'net zero' greenhouse gas emissions.”

While the Climate Alliance is hopeful about this historic step forward in climate policy, much more is needed to be done. We will continue advocating for the advancement of climate solutions that focus on our three pillars of reform: climate justice for communities that have borne the brunt of our current fossil-fuel economy; a true transition for coal miners and other fossil fuel workers likely to be impacted by the transition to a low-carbon economy; and a significant reduction in greenhouse gasses in accordance with the findings of the UN Intergovernmental Panel on Climate Change.

________________

FOUNDED in 2020, the WEST VIRGINIA CLIMATE ALLIANCE is a broad-based coalition of almost 20 environmental organizations, faith-based, civil rights and civic organizations, and other groups with a focus on climate change. Members of the Alliance work together to provide science-based education on climate change to West Virginia citizens and policymakers. 

FOR MORE ON THE CLIMATE ALLIANCE, VISIT: WVClimateAlliance.org

A yo-yo year

 Lots of people I know, myself included, spent a lot of time over the last year trying to get something across the line in terms of a federal reconciliation bill. We started with high hopes and saw things go off the rails on more than one occasion. 

Now, a possible new bill could be voted on very soon, one largely negotiated by a certain senator from West Virginia who has been front and center throughout the process. Although there are plenty of things in the bill not to like, and some things we wanted didn't make it, this is the first major federal legislation to address climate change, while also preserving health care benefits for millions, reducing prescription drug prices, and fixing Black Lung funding.

I'm pleased and proud that this action alert in support of the legislation is at the top of the AFSC webpage.

The United Mine Workers union has also come out strong in support of the Inflation Reduction Act. The release reads in part:

“We are very pleased that Senator Joe Manchin (D-W.Va.) and Majority Leader Chuck Schumer (D-N.Y.) were able to come to an agreement on legislation that includes full and permanent funding of the excise tax that funds the Black Lung Disability Trust Fund. This will give victims of this insidious disease, their families and their survivors some peace of mind that the benefits they so desperately need will never be reduced.

“Senator Manchin never wavered in his commitment to secure the funding for this program, and he delivered. Thousands in the coalfields owe him yet another debt of gratitude, and the UMWA will never forget his dedication to getting this done.

“There is more to do regarding Black Lung, starting with the promulgation of a final rule to limit silica dust exposure in coal mines. We also must examine the entire Black Lung benefits system to make it more inclusive for victims, more efficient in the awarding of benefits, and to ensure its long-term viability in the face of a declining coal industry. The UMWA stands ready to meet with all stakeholders – victims and their families, labor, and industry – to work on solutions to these issues.

“We are also pleased to see that provisions were included in the IRA that will extend tax credits to renewable energy supply chain manufacturers that build plants in the coalfields, which will be a big step toward providing good jobs to these distressed communities. The enhanced tax credits for carbon capture and storage included in the legislation will also be a boon for coalfield jobs. We urge swift passage of this legislation by Congress.”

Now it looks like all eyes are on Senator Sinema. It's nice for once not to have to worry about someone from West Virginia breaking the deal. It would be nicer to finally get this one done.

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.

Not surprised

 I can't say I was bowled over with surprise when I saw this CNN news story about how badly health care in the US compares to other economically advanced countries.

To wit, 

The US once again ranked last in access to health care, equity and outcomes among high-income countries, despite spending a far greater share of its economy on health care, a new report released Wednesday has found.

The nation has landed in the basement in all seven studies the Commonwealth Fund has conducted since 2004. The US is the only one of the 11 countries surveyed not to have universal health insurance coverage.

Commonwealth Fund  president David Blumenthal was quoted as saying "In no other country does income inequality so profoundly limit access to care as it does here. Far too many people cannot afford the care they need and far too many are uninsured, especially compared to other wealthy nations."

However, if you want to look at it from a slightly more optimistic angle, think how much worse all that would be if the Affordable Care Act had been repealed or if the many attacks on Medicaid and other programs had succeeded. All those things were real possibilities not so long ago--and fighting them off took a LOT of work from a LOT of people.

One step at a time I guess.

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.

 

 

Some REALLY good news

 For those who are dreading what promises to be a metaphorical legislative bloodbath in West Virginia, here's some good news for the state and nation.

First a little background. A major provision of the 2010 Affordable Care Act was expanding Medicaid eligibility to 138 percent of the federal poverty level. Originally, that was supposed to be applied across the board, but the US Supreme Court made it a state option when it ruled the ACA to be constitutional in 2012.

By now, 39 states, including DC, have extended the coverage, which is life saving and game changing in so many ways, from supporting jobs to opening the door to recovery. You can probably guess many of the states that haven't expanded it if you think of the Civil War. Thank God West Virginia isn't on that evil list.

When Trump became president, a major goal was total repeal of the ACA. It was scary for a long while, but eventually that idea went the way of the whole Mexico-paying-for-the-wall thing. However, his administration did encourage states to apply for waivers that would require people in the expansion population to meet so-called "work requirements." 

These didn't promote work but rather paperwork, reporting and surveillance on a population that mostly consisted of people already working. These would have resulted a huge portion of people in the program being cut off for no good reason. Some states applied, but their waiver plans were blocked by the courts.

In West Virginia, we've worked with allies to fight off at least two serious efforts to seek Medicaid waivers and until today were expecting more, which brings us to the good news part of the program. According to an article in today's Washington Post, 

The Biden administration is planning Friday to wipe out one of the core health policies of the Trump era, taking actions that will immediately rescind permission for states to compel poor residents to work in exchange for receiving Medicaid benefits.

Federal health officials will withdraw their predecessors’ invitation to states to apply for approval to impose such work requirements and will notify 10 states granted permission that it is about to be retracted, according to a draft plan obtained by The Washington Post and confirmed by two individuals familiar with the decision, who spoke on the condition of anonymity because they were not authorized to discuss the matter publicly.

So it looks like that's one less thing to worry about. I'll take it.

 

Long strange trip

 I've been wracking my brain trying to think of what to say about the events of the week and the years that went before it. For most of the fall, I've been very concerned about the possibility of a coup, quasi-legal or otherwise. I'm still wondering what kinds of violent stunts white nationalist groups may unroll and what other long term damage has been done to the democratic process, imperfect as it is. 

I'm hoping that the nation's flirtation with fascism or at least authoritarianism is at least waning.

Aside from issues of authoritarianism, the last four years have involved a lot of defensive fights, mostly revolving around health care (food security too, but that's another story). If there's been a central theme of my nearly 32 years at AFSC, health care would be it.

My first big fight was the Pittston strike, which was mostly about retiree health and pension benefits. These were also factors in the 1990 teachers' strike and the 1990-92 Ravenswood lockout. Ditto the fights about "reforming" workers compensation that lasted for a decade between the mid 1990s and 2000s. 

The coming of welfare "reform" in 1996 started another decade or so of sporadic fights related to Medicaid. These included issues like transitional coverage for people leaving cash assistance, the possibility of block grants, waivers and such. 

Then came efforts to get the state to implement the federal Children's Health Insurance Program in 1998 and then to expand eligibility for it, eventually up to 300 percent of the federal poverty level by 2011. My late co-worker Carol Sharlip was a major player in building support for this in the early years.

In 2009-2010 came the push to enact what eventually became the Affordable Care Act. I remember going to public hearings around the state and witnessing the WV version of the birth of the white backlash and the Tea Party. These included paranoid ravings about the World Health Organization taking over and someone heckling a priest during an opening prayer. And, yes, people who wanted to keep the government's tentacles off Medicare. There were street actions, press conversations, calls, emails, op-eds, bus trips to DC, and all that. Then lots of outreach and education when it passed.

(There were some serious debates within AFSC about whether to sign on in support of the bill. Some didn't think it was good enough. I may or may not have stopped talking with some people after that.)

The version we got was the Senate's rather than the more generous House version in March 2010. Here's a blog post I wrote about it at the time. Then the 2012 US Supreme Court decision which let it stand but made Medicaid expansion--the real public option--a state decision. The biggest social justice victory of my lifetime was then-Governor Tomblin's decision to expand it. Here's a report we published in an effort to nudge the governor in 2013. My retired colleague Beth Spence did the interviews and photography.

I would never have guessed the state would do such a great job at enrolling people. At it's peak around the time of the 2016 election, the expansion covered nearly 180,000 West Virginians (after four years of assaults by the Trump administration, I think enrollment is around 160,000 now). The new president, aided by WV's attorney general, promised to do away with the whole ACA as soon as he came into office.

It was an all-hands-on-deck moment. Health advocates scrambled to the defense. My co-worker Lida Shepherd and I worked with Cabin Creek Health Systems to interview people covered by the ACA and publish the results and generate other media, including a widely seen video report in the New York Times. Given that WV has been ground zero for the opioid epidemic, protecting the ACA, which opened up recovery to thousands, was critical.

We worked with allies to do all the usual stuff. Some friends of ours, nicknamed "the Capito six," were arrested for sitting in at the WV Republican senator's Charleston office. I remember protesting outside WV's giant Boy Scout center when the President spoke. People put lots of effort into bolstering Senator Manchin's support for the ACA. He eventually came around to a "fix, don't nix" position. In a closely divided Senate, WV was in a critical spot, with a conservative Democrat and fairly moderate Republican. People hit it with all they had.

The critical moment came in July 2017 when a dying John McCain cast a deciding vote after returning from hospital treatment for brain cancer, basically saving the day. Here's a post on that occasion that includes his eloquent statement.

After a pause to catch our breath, WV health care advocates turned next to fight off bad state legislation regarding work reporting requirements for Medicaid expansion that would have kicked tens of thousands of low income West Virginians off the program in 2019 and 2020. I'm hoping that COVID-19 has shown this to be a Really Bad Idea.

By the time of the 2020 election, the ACA was battered but still afloat, although it wasn't clear if it could survive another four years of federal assaults. Then there was the added wrinkle of the US Supreme Court taking up another repeal attempt with three Trump appointees. The decision is expected as soon as this spring, but early deliberations seem promising.

So I guess this is another catch the breath moment. We're still far from universal care, but it's been a long hard fight to get as far as we have. I'm grateful to the many friends who have been in the fight from the beginning. Like the ACA, we're battered but still around.

Thinking ahead

 Well THAT was interesting. I'm hoping today's results will signify the end or at least the beginning of the end of America's latest dark journey, although I think we're not out of the woods yet.

I've been thinking a lot about my walk across Spain two years ago on the Camino de Santiago. More than once I passed through what were mass graves of people like me who were murdered by Franco's fascists during the Spanish civil war of the 1930s. For the last few years, I kept reminding myself that many admirable nations had gone on journeys as bad and much worse than ours but eventually emerged.

Still there's a lot to watch out for. Lot's of people, including myself and colleagues with the American Friends Service Committee, have been thinking about worst case election related scenarios, up to and  including the possibility of a coup. We of course are willing to accept an outcome that accepted all votes but were worried about other irregularities that might threaten the integrity of the eleciton, such as voter suppression and/or intimidation.

Assuming the constitutional anchor holds, the next big fight starts next week, when the freshly stacked deck of the US Supreme Court will consider taking away the health care of millions of Americans, to the delight of West Virginia's attorney general Patrick Morrisey.  There are any number of scenarios there.

Keeping that assumption, we might be in for gridlock in Congress but will at least be spared an American approximation of authoritarianism. 

West Virginia is going to be weird in any case. But, as my late friend and WV poet Norman Jordan, who with his wife Brucella operated an African American heritage museum in his home town of Ansted for years, wrote in a funny poem, I guess you can't have everything.

On the positive side, and assuming no funny stuff, we're going to see the end of a federal department of education, led by someone who never attended any institute of public education, trying to sabotage it. We're going to see the end of administrative policies aimed at taking away food assistance of millions of low income Americans and public school students. 

Assuming parts of the Affordable Care Act remain, we're likely to see the end of federal policies encouraging states to impose bogus work reporting requirements designed to deprive people of health care. We might at least see some harm reduction on the climate change front.

There's still so much to do. Many people with whom we disagree were our friends and allies not so many years ago. The country is still tragically divided. Even with a peaceful transition, many of the policies some of us hope to see will be blocked  until that is changed.

But I'll think about that tomorrow.

Counting the cost of health care repeal

 It’s too soon to say, but the people who want to overturn the Affordable Care Act, a group that includes West Virginia’s attorney general, are closer than before to getting what they want, even in the midst of a pandemic that has already killed over 200,000 Americans.

Opponents of the ACA, often referred to as Obamacare, give many reasons for wanting to kill it, although I suspect that, for many, the main reason is that it can be associated with a Black man.

But what would it mean for ordinary Americans if the ACA haters get what they want? The answer is pretty grim, if you do the math.

One feature of the ACA is protection of people with preexisting conditions in qualifying for health insurance. According to the federal Department of Health and Human Services, as many as 133 million Americans, over half of the non-elderly adult population, have some such condition.

Given the frailties of the human body, it has been argued that “life is a preexisting condition,” or at least one waiting to happen. This was especially true for women before the ACA passed, for reasons of medical costs associated with pregnancy, breast cancer and conditions unique to them. The National Women’s Law Center said that before the ACA “just being a woman could be considered a preexisting condition.”

Then there’s Medicaid expansion, a part of the ACA that became a state option after a 2012 U.S. Supreme Court decision. According to the Kaiser Family Foundation, 39 states and the District of Columbia, have adopted this measure, which covers about 12 million Americans, most of whom are low-income working people and many of whom are the “essential workers” that everyone else depends on these days.

The ACA guarantees that states that adopt the expansion will never have to pay more than 10 percent of the costs. Without it, states would be unable to sustain coverage.

About 160,000 West Virginians are covered by the expansion at any given time and probably 200,000 or so are covered during a year. Aside from improving and saving lives, federal expansion funding also helps keep rural hospitals and health care facilities open and supports thousands of jobs.

Medicaid expansion has been a huge help in confronting the opioid epidemic. According to the Georgetown Center for Children and Families, “Medicaid expansion was associated with a substantial increase in opioid addiction therapies, particularly in states with high opioid overdose rates.”

Nationwide, about 800,000 Medicaid expansion recipients are dealing with opioid addiction.

A 2020 article in the Journal of the American Medical Association found that states that adopted Medicaid expansion had a decrease in opioid deaths, compared to states that hadn’t expanded Medicaid.

I’ve interviewed people in recovery about the role Medicaid expansion has played in their access to treatment. One woman summed it up neatly: “Without it, I’d be either dead or in jail.”

Then there are those who buy health care on the marketplaces. Kaiser reports that, in 2020, this amounts to 11.4 million Americans and over 20,000 West Virginians. Of these, an investigative article in The New York Times said that, “If the marketplaces and subsidies go away, a comprehensive health plan would become unaffordable for most of those people and many of them would become uninsured.”

The Times also reports that ACA repeal would hit Medicare recipients as well, affecting around 60 million Americans and over 440,000 West Virginians. Among other effects, if the law were struck down, “Medicare beneficiaries would have to pay more for preventive care, like a wellness visit or diabetes check, which are now free. They would also have to pay more toward their prescription drugs.”

Young Americans also would take a hit. The ACA allows about 2 million young adults to keep their parents’ health insurance up to age 26. The last numbers I could find suggest that about 20,000 young West Virginians are covered in this way. Without it, companies could withdraw coverage.

Killing the ACA also would dramatically increase the cost of health care, including uncompensated care, raising copays and premiums as these costs are passed on to individuals and families. The Urban Institute reports that “Demand for uncompensated care would increase by $50.2 billion, an increase of 82% compared with ACA levels.”

Oh yeah, and then there’s the prospect of millions of Americans losing health coverage while COVID-19 is still ravaging the country and the world.

To sum it all up about ACA opponents, and to paraphrase Winston Churchill, seldom have so few tried to do so much harm to so many. God help the country if they get what they want.

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

Another one to watch

I've kind of been obsessed with health care policy for pretty much my whole career with the American Friends Service Committee, which began in 1989.

The first big fight I ever had, the Pittston coal strike (1989-90), was largely about health benefits for coal miners and their families, especially for retirees. Health care was a major issue in other good labor struggles from the Ravenswood Aluminum lockout (1990-92) to the recent WV work stoppages by teachers and school service workers.

In terms of public policy, lots of fights in the era of welfare reform (1996-early 2000s) had to do with health care. These included enacting the Children's Health Insurance Program at the federal level, followed by several pushes here to get the state to implement and expand the program. That culminated in 2011, when then Governor Tomblin expanded eligibility to 300 percent of the federal poverty level.

There were also efforts in that period to make sure people got "transitional Medicaid" when they left public assistance, along with supportive services related to minimal dental and vision care.

Then came the epic struggle to enact the Affordable Care Act. Misnamed Obamacare, it's really more like the Senate version of a reform bill. The House version was better, but with the death of Senator Edward Kennedy in August 2009, the senate version was the only game in town. It passed in March 2010.

I remember all hell breaking loose at town meetings in WV and around the country in 2009. At one in Huntington, a conspiracy theorist argued that reform meant something like a military takeover by the World Health Organization. You know, black helicopters and microchips in the butt. Apparently, they haven't made it out my holler yet.

At another event in southern WV, a  Catholic priest got heckled by someone during the opening prayer, with a shout of "How much are you getting paid?"

Efforts to repeal it began as soon as efforts to defeat it in Congress failed. In 2012, the US Supreme Court weighed, affirming the constitutionality of the law but making a key piece of it, Medicaid expansion, a state option.

People here worked hard to persuade Tomblin in 2013 to make the expansion, which he did with characteristic caution, seeking an actuarial opinion that fortunately underestimated the benefits of the expansion to WV. The effects were and are huge.

While quite a few states jumped on right away, others, particularly in the south and west, held out. A series of state by state fights ensued. I think each time a state decides to expand it, the harder it will be to undo the whole thing.

(I'm going  to skip over the epic fights since the 2016 election to block Trump, WV attorney general Patrick Morrisey and others of that ilk to take it all away from millions of Americans, not to mention the next US Supreme Court ruling, which is expected to come early next year. I get tired just thinking about it.)

The last time a state expanded Medicaid was in Oklahoma in June, where voters narrowly approved the expansion despite a flood of dark money..

Which brings us to tomorrow, when voters will take up the measure in Missouri. The following alert went out from Joshua Saleem, director of AFSC's St. Louis program to Friends and contacts in that state:

On August 4, Missouri voters will have the chance to make history and save lives by voting “Yes!” on Amendment 2, which would expand Medicaid to cover around 200,000 currently uninsured state residents. The expansion would particularly benefit adults in working families earning up to 138% of the federal poverty level.

This step makes sense in “ordinary” times by extending health care, opening the path to recovery from addiction, easing the path to reentry for formerly incarcerated people, supporting hospitals and health care providers, creating jobs and generating economic activity—but these aren’t ordinary times. In these times of a global pandemic that has yet to slow down, a yes vote is absolutely imperative.

Medicaid expansion is a provision of the 2010 Affordable Care Act. It was intended by Congress to apply across the nation, but a U.S. Supreme Court decision made it a state option.  As of now, 38 states, including the District of Columbia, have expanded Medicaid. Missouri should join their ranks.

The vote could be close. In Oklahoma, voters approved the expansion in June—but by a bare margin of one percent. Millions of dollars in dark money will be spent to defeat the measure.

This is why we’re asking you do three things: vote yes, share this email with friends, and do all you can to get out the vote.

Since its founding over 100 years ago, the American Friends Service Committee, following the Quaker belief in the value of all persons, has worked to promote economic rights as human rights. It has supported access to health care internationally as well as at the national and state level in the United States.

It doesn’t often happen that ordinary people have the opportunity to make such a huge difference with such simple steps, but this is one of those times. Please help us make the most of it.

It will be the latest round in a series of struggles that probably began in the USA in 1912 when former president and presidential candidate Theodore Roosevelt first proposed something like universal health care as the candidate of the Progressive Republican Party.

I plan on staying up as long as it takes for the vote to be counted.











 

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).

Happy 10th, Affordable Care Act!

Happy 10th birthday, Affordable Care Act! Here's a blog post I wrote at the time President Obama signed it into law:

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.

Just thinking

There's nothing like a good outbreak of some kind to make you think about things. Here are some things I'm thinking about these days:

*WV attorney general Patrick Morrisey joined the lawsuit to repeal the Affordable Care Act. How's that going down with the coronavirus outbreak?

*The US Supreme Court has taken up the case to repeal the Affordable Care Act. It would be...interesting if they did that with all this going on.

*Whatever happens, this highlights the importance of things like paid sick days for all workers, universal health care, investing in public health (and science education), and things like plans for feeding kids when they're out of school for whatever reason. We've got a lot of unfinished business.

Lessons from Louisiana?

One of the more interesting news stories in the last few days was the reelection of Louisiana governor John Bel Edwards. It was a state that went heavily for Trump in 2016 and he campaigned heavily there before the election.

As was the case in Kentucky's race, a key factor was Medicaid expansion. Kentucky's Bevin tried to undo a lot of that state's progress in expanding health care (around 400,000) by imposing draconian reporting requirements that would have cut off tens of thousands. Edwards made the decision to expand Medicaid in his previous term, where it now covers around 500,000 people.

Here's an interesting take on the politics of Medicaid and what it might mean for the future. Sample quote: "In the last two years, Obamacare in general — and Medicaid expansion, in particular — have begun paying political dividends."

I'm reminded of a quote from the Psalms, "The stone the builder refused has become the chief cornerstone."