Saving Medicaid: in their own words

 While going through some old files, I came across a copy of an interesting letter dated June 29, 2017, from then Governor, now Senator, Jim Justice to Senator Shelley Moore Capito. The subject was the looming threat of the repeal of the Affordable Care Act (ACA) and especially Medicaid expansion.

Here are some excerpts:

Since so many of our people count on Medicaid, any cut to Medicaid would destroy families in West Virginia. We can’t put the 175,000 West Virginians who benefit from the Medicaid expansion at risk of losing coverage. The consequences would be beyond catastrophic.

In the face of our drug epidemic, fewer people would have access to drug treatment programs under the current proposal. As the debate moves forward, I hope you and your colleagues will consider the fact that it will only make it harder to combat the drug problem that’s ravaging West Virginia.

I think he nailed it then—and his words still apply today, arguably more than ever.

To her credit, Senator Capito issued this statement on July 18 of that year:

As I have said before, I did not come to Washington to hurt people. For months, I have expressed reservations about the direction of the bill to repeal and replace Obamacare. I have serious concerns about how we continue to provide affordable care to those who have benefited from West Virginia’s decision to expand Medicaid, especially in light of the growing opioid crisis. All of the Senate health care discussion drafts have failed to address these concerns adequately.

My position on this issue is driven by its impact on West Virginians. With that in mind, I cannot vote to repeal Obamacare without a replacement plan that addresses my concerns and the needs of West Virginians.

I think she nailed it too.

Eight years later, we’re facing a similar threat. This time around, the issue isn’t directly repealing the whole ACA, although it might as well be. Instead, it’s a federal budget reconciliation package that would cut $880 billion from Medicaid (not to mention $230 billion in SNAP food assistance and $12 billion in school meal funding) to pay for more tax cuts for the very wealthy.

A cut that huge would truly be, as Justice said, beyond catastrophic across the US and especially in low-income states like West Virginia. Our already dismal health statistics would get worse. Minor issues will turn major. Substance use disorder will go untreated. The cost of emergency room visits and uncompensated care will grow and be passed on to others. Rural hospitals will close. Jobs will be lost. And people will die.

The margins in Congress are razor thin. Our senators’ votes could influence the final outcome, especially after the House voted to throw us under the bus. I hope they take their own advice and side with the people of West Virginia again.

(This appeared as a column 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 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 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.

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.

 

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.











 

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).

Interesting times

I don’t know if it’s authentic, but supposedly there’s an ancient Chinese curse that goes, “May you live in interesting times.”

(According to the late British author Terry Pratchett, there are two related curses. One is, “May you come to the attention of those in authority,” and the other is, “May the gods give you everything you ask for.” He wasn’t sure about the authenticity of those either.)

At any rate, our time is getting a bit too interesting for my preferences. It’s very rarely a good thing when a historical event on a global scale comes knocking on the door. I’m thinking of things like the decision to invade Iraq, the Sept. 11 terrorist attacks, the bombing of Pearl Harbor, the assassination of Archduke Ferdinand in Serbia in 1914 — not that I was around for all the above.

I’m reminded of a quote about history by the great German philosopher Georg Wilhelm Friedrich Hegel, who spoke of it as “the slaughter-bench at which the happiness of peoples, the wisdom of States, and the virtue of individuals have been victimized ... .”

Now that’s a cheery thought.

I think it’s interesting that the ancient Greeks had two words for historical time, chronos and kairos. Chronos referred to ordinary, not-too-interesting times — business as usual. Kairos meant a special time of challenge, crisis or decision. In the New Testament, for example, when Jesus said things like “the time is fulfilled” (Mark 1:15) or “my time is not yet come” (John 7:6), the word was kairos.

If there ever was a time of kairos, this is one.

Another word of Greek origin comes to mind, as well: apocalypse. Contrary to common usage, the word itself has nothing to do with the end of the world. Rather, it means something like uncovering, revealing or lifting the veil.

I’m hoping this crisis has lifted the veil on the world we live in. It has revealed that the real heroes who keep everything going aren’t hedge fund managers, CEOs or billionaires, but the helpers, retail workers, drivers, etc., who often work for low wages and no benefits. That needs to change.

It has revealed that health care, investments in public health and paid sick days aren’t luxuries or utopian notions, but necessities.

It has revealed the bankruptcy of an ideology that worships markets and the private sector while disparaging public goods and services, reasonable regulations and democratic and accountable governance.

It has revealed that entrusting government to those who believe government can’t do anything doesn’t bring about good government.

It has revealed that we ignore science to our peril.

And it’s a reminder that we need to pay more attention to the natural world we depend on — before it pays more attention to us.

Hegel also said, “What experience and history teach is this — that peoples and governments never have learned anything from history, or acted on principles deduced from it.”

For all our sakes, I hope he’s wrong about that.

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

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.

How not to save rural health care

Recently, Gov. Jim Justice called for the creation of a task force to address West Virginia’s rural health systems. It’s a timely idea. Hospitals from the northern panhandle to the southern coalfields are facing a sea of troubles, from bankruptcies to layoffs to outright closings.

It’s a nationwide problem. According to researchers at the University of North Carolina, since 2005, 163 rural hospitals have closed around the country. Of those, 121 have closed since 2010. Last year saw the highest number of closings since 2005, with 19 hospitals closing their doors.

According to a national investigation by GateHouse Media, another 700 are “on shaky ground,” and around 200 are “on the verge of collapse.”

Looking at national trends, 72 percent of rural hospitals that closed did so in states that chose not to expand Medicaid.

As scary as things are here, they’d be a lot scarier if the state hadn’t made the decision to expand Medicaid back in 2013 to working people earning up to 138 percent of the federal poverty level. In 2018 alone, the expansion brought over $900 million to the state.

That money didn’t go to buying junk food or Mountain Dew. It went to providing preventive care, treatment for acute and chronic diseases, injuries and, when necessary, treatment for recovery from addiction. It also helped shore up health care providers, from hospitals to community health centers to physicians to nurses to other health care workers. And that means supporting local jobs and economies.

Here’s a modest proposal: While we’re trying to figure out how to make our rural health system better, let’s not make things worse by messing with Medicaid.

Unfortunately, a bill introduced in the legislature would do just that. House Bill 4018, if enacted, would make a bad situation worse by imposing reporting requirements on people covered by the program. The bill does nothing to actually promote employment — most of the people covered are already working. Instead, it creates another level of paperwork, bureaucracy and surveillance, wasting time and resources that could be better spent on getting and keeping people healthy.

The bill is similar to a failed policy enacted in Arkansas that was fortunately struck down in federal court. Before being shut down, the program needlessly cut off between one-fourth and one-third of people in the program, with no positive effect on employment.

Not only that, but it unnecessarily wasted taxpayer money. An audit by the nonpartisan Government Accountability Office (GAO), an investigative arm of congress, found the reporting requirement wound up costing that state $26 million. That added up to an unnecessary $152 in excess overhead costs for each person enrolled in the program.

If something like this was tried in West Virginia, assuming it would stand up in court (with all those associated costs) and assuming similar results, this would mean that somewhere between 40,000 and 53,000 of the approximately 160,000 beneficiaries would lose coverage. That means people not getting needed health care. And that means a proportional reduction in the $900+ million the expansion now brings to the state, not to mention millions in additional costs.

It’s a good thing to create a task force to figure out solutions. But for all kinds of reasons, let’s not make a tough situation worse by pulling the plug on rural health care’s life support system.

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

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."

Saving lives

Back in 2013, thousands of West Virginians came together to urge then Gov. Earl Ray Tomblin to expand Medicaid coverage to low income working adults under the Affordable Care Act.

He did.

(In retrospect, there was a good chance he would have done it anyway without all the shouting, but nobody wanted to leave that to chance.)

At the time, many advocates argued that doing so would save lives. Or, conversely, that failing to do so would cause unnecessary deaths.

The original federal legislation mandated expansion nationwide, but a 2012 U.S. Supreme Court decision made this a state option. That court decision, in effect, would prove to be a death sentence for thousands of Americans.

After five years of Medicaid expansion, researchers did the math, comparing mortality rates for low income “near elderly” Americans aged 55 to 64 in states that did and did not expand Medicaid. That demographic is more likely to benefit from coverage — and to suffer without it — than younger and presumably healthier Americans and elderly people eligible for Medicare.

The results, published by the National Bureau for Economic Research (NBER), found a .13 percentage point reduction in mortality for states that expanded Medicaid compared with those that did not.

According to the researchers, “The effect is driven by a reduction in disease-related deaths and grows over time.”

Specifically, 15,600 people died between 2014 and 2017 because their state didn’t expand Medicaid. That’s about five times the death toll from the 9/11 terrorist attacks.

If some other country would have caused that many American deaths, we would have gone to war.

In West Virginia, the news was better. Over the same period, the number of uninsured West Virginians fell by 56 percent. According to the NBER research, the expansion saved 87 lives per year in the Mountain State. That would be 435 lives over the five years the expansion has been in place.

And that’s just for the “near elderly.” The overall numbers would be higher.

It’s important to remember the life-saving facts about Medicaid expansion, which now covers over 155,000 West Virginians.

The program is under attack both by a federal lawsuit, supported by the state’s attorney general, and by potential state legislation that would impose work reporting requirements which could kick 38,000 to 71,000 out of coverage.

The research shows that this is literally a matter of life and death.

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

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 belated birthday

Sometimes I miss a birthday by a day or even a few. Such is the case this time with the 10th anniversary of the signing of the Affordable Care Act. 

Personal note: I have put my time into that puppy, from supporting its passage, to pushing for Medicaid expansion to defending it from attacks. It was a far from perfect piece of legislation, but it was what we could get at the time.

Just for fun, below is an excerpt from a Goat Rope post I wrote at the time. The title was Signed. Sealed. Delivered.

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.

Messing with Medicaid is a bad idea

Back in May of 2013, then-Gov. Earl Ray Tomblin made the decision to expand Medicaid coverage to low-income families earning up to 138 percent of the federal poverty level.

By that one act, I think he did more to relieve unnecessary human suffering than any number of his predecessors. Maybe more than all of them put together.

Medicaid expansion was an option under the Affordable Care Act. It was originally intended to apply to all states, but this provision was struck down by the US Supreme Court in 2012. Since then, it has become a state option.

That decision has been a lifesaver and a game changer for tens of thousands of West Virginians. As of Feb. 19, 158,137 West Virginians are enrolled in Medicaid expansion. That’s a little shy of one out of 10 state residents, but not by much. In any given year, around 200,000 people have received coverage due to Medicaid expansion.

Most people who gained health coverage came from working families not otherwise eligible for traditional Medicaid.

A lot of the credit for that goes to the West Virginia Department of Health and Human Resources, which did an amazing job of reaching out to and enrolling eligible citizens.

I’m not sure how much this weighed on Gov. Tomblin’s decision at the time, but the expansion opened the gates of treatment for addiction and, ultimately, recovery for thousands of West Virginians struck by the opioid epidemic.

In the words of Nan Whaley, mayor of Dayton, Ohio, a city that has made great progress in reducing overdose deaths, “If you’re a state that does not have Medicaid expansion, you can’t build a system for addressing this disease.”

Not only did West Virginia do something right, but it did it well. That’s the good news.

The bad news is that there’s a move in the Legislature to impose a policy that has failed elsewhere. The House Finance Committee recently voted to impose on West Virginia a policy that has caused a great deal of unnecessary suffering in Arkansas.

The failed policy sounds good, at a superficial level: Let’s impose work requirements on those who receive expanded Medicaid coverage.

I’ve used this Bible verse more than once, but it still fits: “There is a way which seemeth right unto a man, but the end thereof are the ways of death.”

Instead of promoting work, it increases bureaucratic costs and reporting requirements and results in cutting people off for no good reason.

By August 2018, over 18,000 enrollees out of 62,000 — nearly one out of three — in the Arkansas program had been cut off. There’s no evidence whatsoever that those people are doing more work, but it’s a safe bet that they are worse off.

Closer to home, Kentucky has applied for a waiver to impose a similar but more draconian work requirement on its Medicaid population. According to the research of Simon Haeder of West Virginia University’s Rockefeller School of Policy and Politics, if West Virginia would follow suit, this would impact 95,000 West Virginians, including those who are unemployed or who are working but can’t get enough hours to meet the requirement.

Even if we just assume that West Virginia’s results would be similar to those in Arkansas, we would see over 46,000 people losing coverage. That would be about the same as the entire population of Huntington or Charleston — or of Pocahontas, Doddridge, Calhoun, Pleasants, Pendleton, Tucker and Wirt counties combined.

Apparently, some people didn’t get the memo that having health care isn’t a barrier to employment, it actually helps you stay in the game. I know plenty of people, myself included, who are working and paying taxes today but would probably have been disabled or dead without health care.

For that matter, cutting people off from Medicaid doesn’t just hurt those individuals, it also affects local hospitals and health care providers, reduces money coming to local communities and can have a negative effect on employment. And it drives up health care costs for everyone else by increasing emergency room visits and uncompensated care.

The main support for this seems to come from the same kind of outsider-funded astroturf groups that gave us education “reform.” Last year, one of these types of bills succeeded, resulting in new state code that took basic food assistance away from homeless people.

It’s sad to say, but some people in power evidently derive some kind of weird gratification by imposing misery on those less powerful.

Somehow, however, I don’t think most West Virginians are into that kind of thing.

I hope the majority of West Virginia legislators ultimately agree.

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

Stating the obvious

It's been five and a half years since then Governor Tomblin (where are you when we need you?) decided to expand Medicaid coverage for low income working West Virginians under the Affordable Care Act. A recent study by the Georgetown University Center for Children and Families found what you might expect: it was a good idea, one that literally changed and saved lives.

As I mentioned in the last post, the recent election not only strengthens the position of those states that have expanded the program--it opens the way for Medicaid expansion in several holdout states. According to the Center on Budget and Policy Priorities,

"If all remaining non-expansion states (including Idaho, Nebraska, and Utah) adopted the expansion in 2019, more than 4.5 million uninsured people would gain coverage and uninsurance rates in these states would fall by a quarter, according to Urban Institute projections."

Let's hope we get there.

Another state does the right thing

In case you missed it, there was a pretty major victory for working people and for social justice recently. The Virginia legislature voted to expand Medicaid under the Affordable Care Act, with the full support of the governor.

Of course, this could have happened four years ago and helped a lot more people a lot sooner, but a different team was running their legislature at the time. All that changed after the 2017 election. Since then, the measure even gained bipartisan support.

In the parlance of our time, this is a YUGE deal for more than one reason. The first, obviously, is that many more low-income people, most of whom live in working families, will be eligible for health care, including treatment for people trying to recover from addiction. To the tune of 400,000 people.

In addition to covering more people, the Commonwealth Institute for Fiscal Analysis estimates the expansion will bring over $2 billion in federal funding to the state, create 18,000 jobs and increase state tax revenues by $88.6 million.

I’d say congratulations are due to everyone there who fought the good fight.

West Virginia fortunately made the decision to expand Medicaid back in 2013, thanks to then-Gov. Earl Ray Tomblin. As of now, around 165,000 West Virginians are covered by it. In any given year, that could be as many as 200,000 people, or one out of nine adults, including tens of thousands in recovery. That decision has also created jobs, boosted local economies and helped keep rural hospitals and community health centers afloat here.

That decision is probably Tomblin’s greatest legacy as governor and one that will be hard for any other governor to match, past, present or future.

Which leads to another reason why Virginia’s decision is a big deal: the more states that take advantage of the expansion, the tougher it will be to undo it at the federal level (and the more likely West Virginia will continue to benefit from it). So far, 33 states and the District of Columbia have expanded Medicaid.

Interestingly, no state that has flipped to Republican since deciding to expand it has reversed the decision. And several more conservative-leaning states are moving in that direction.

Last year, Kansas’ Republican legislature passed expansion, only to have it vetoed by Gov. Brownback. That could be revisited. Maine voters supported expansion last year in a ballot measure. The governor there has refused to implement it, but he faces term limits and it’s likely the next governor will be less indifferent to human misery. Utah will vote on a further expansion in November, while efforts to get the measure on the ballot are in progress in Idaho and Nebraska.

During North Carolina’s massive teacher protests, educators called for Medicaid expansion in addition to better funding for schools.

And to think that only a few months ago it looked like all that would have been wiped out by the Trump administration and the oligarchs in Congress.

That was a long, tough fight, and it's not over yet. It's likely that the Trump administration will keep pushing states to apply for waivers restricting coverage and cutting people off. It’s anyone’s guess as to whether officials here will take the bait. But they'll have a tough time pulling the plug on the whole thing.

Obviously, while Medicaid expansion is a great advance, it doesn’t cover everyone who needs health care. Many are still uninsured or have poor or unaffordable coverage.

We still have a long way to go to get to truly universal and affordable health care, possibly with something like an improved version of Medicare available to all. But it’s important to defend the ground we’ve gained and resist all efforts to roll them back even as we prepare to move forward again.

That may have gotten just a little bit easier.

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

Congress needs to fix CHIP-fast

Congress needs to protect kids. The other kind.

West Virginia is often at the top or bottom of lists of states. Not in a good way.

One exception to this - at least up to now - is its Children's Health Insurance Program (CHIP).

CHIP was enacted with bipartisan support by Congress in 1997 in the wake of sweeping welfare reform legislation that would lead to millions of poor families with children losing benefits.

In a moment of humanity that seems sadly distant today, Republicans and Democrats recognized that children should not suffer as a result of these policy changes. CHIP was intended to provide coverage to children in working families where the parents didn't have employer-provided health insurance, something which is all too common.

Our then-Sen. Jay Rockefeller played a key role in getting CHIP passed.

In the spirit of the "new federalism" that prevailed at the time, enacting and expanding CHIP was a state option.

It took a bit of a fight - in which churchwomen played a key role - but the West Virginia Legislature moved to enact the program in 1998. At first, the program supplied coverage to children under 100 percent of the federal poverty level.

Since then, the eligibility level has been raised several times, most recently by former Gov. Tomblin in 2011 to cover children under 300 percent of the poverty level.

It's one thing to get something passed and another to get kids signed up. This is where West Virginia really took the lead. Over a period of nearly 20 years, public and private efforts have combined to provide near universal enrollment of eligible children.

As of August 2017, fully 97 percent of state children have health coverage. That put us in the top 10 states for covering kids.

That's the good news. The bad news is that Congress failed to reauthorize the program by the Sept. 30, 2017, deadline. Apparently, it had other priorities, such as making the very rich richer at the expense of everyone else.

At the very last minute before the holidays, Congress finally passed a temporary fix for CHIP - but only through March. At the time, 16 states were going to run out of funding for the program by the end of January and most of the rest will hit bottom soon after. This would have meant around 9 million children and 370,000 pregnant women losing coverage. For some of them, CHIP is matter of life and death.

A temporary fix is nice, but just that. Congress needs to wake up and do the right thing for the long term. And West Virginia's delegation needs to lead the way.

(This op-ed appeared in Sunday's Huntington Herald-Dispatch.)