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Better Dead and Red: How the GOP Blocked Health Care for Red State Americans

September 30, 2013

For two decades, Republicans have opposed health care reform not because they thought it would fail the American people, but because they feared it would succeed. Passage of Bill Clinton's health care program, Bill Kristol warned in 1993, wouldn't just "do everything to help Democratic electoral prospects," but would "revive the reputation" of the Democrats "as the generous protector of middle-class interests." Sixteen years later in November 2009, Utah Senator Orrin Hatch confessed his worry that if the Affordable Care Act became law, "you're going to have a very rough time having a two-party system in this country, because almost everybody's going to say, "All we ever were, all we ever are, all we ever hope to be depends on the Democratic Party."
That overriding fear--that a grateful American public would reward the Democratic Party with an enduring majority for adding the third and final pillar of health care to the social safety net alongside Social Security and Medicare--has fueled the fire of conservatives' scorched-earth opposition to Obamacare. But with enrollment in the new health insurance exchanges set to start on October 1, Republicans are running out of time and tactics to defund, delay or destroy the Affordable Care Act. And in what is the supreme irony of the GOP's unprecedented campaign to sabotage the ACA, the real damage has already been done in the reddest of red states.

Study after study has long shown that health care is worst in precisely those states where Republicans poll best. But in their zeal to discredit a president they loathe, GOP leaders across the nation passed up an historic opportunity to bring health insurance, greater financial security and higher standards of living to millions of their own constituents. When they didn't outright deny coverage to red state residents, Republicans did their damnedest to prevent their voters from even learning about their options under the ACA. And what "information" about Obamacare the GOP's best and brightest regurgitated simply wasn't true.
Here's how they did it:

(Click a link to jump to the details below.)
Millions Needlessly Left Uninsured...
In May 2009, the Washington Post ("A Red State Booster Shot") summed up how national health care form would ultimately have to work--and have to be funded. In a nutshell, it would become yet another case of "red state socialism" in which blue state taxpayer dollars flow to the federal government to pay for benefits their Republican-led brethren will enjoy:

Health-care reform may be overdue in a country with 45 million uninsured and soaring medical costs, but it will also represent a substantial wealth transfer from the North and the East to the South and the West. The Northeast and the Midwest have much higher rates of coverage than the rest of the country, led by Massachusetts, where all but 3 percent of residents are insured. The disproportionate share of uninsured is in the South and the West, the result of employment patterns, weak unions and stingy state governments. Texas leads the way, with a quarter of its population uninsured; it would be at the top even without its many illegal immigrants.

But as the Department of Health and Human Services (HHS) recently forecast, roughly 11 million Americans will needlessly be left uninsured at the end of 2014 mostly due to Republican governors and state legislatures that refused to accept Obamacare's expansion of Medicaid within their borders. With studies from Families USA, the Urban Institute and Harvard Medical School putting the unnecessary death toll for the uninsured as high as 45,000 a year, the blame for the body count will be placed at the feet of the real death panelists of the GOP.
Reuters ("U.S. government scales back Obamacare impact for 2014") explained the dynamic at work in GOP-controlled states:

The biggest factor in the change stems from the U.S. Supreme Court verdict last year allowing each state to decide whether to expand the public Medicaid program for the poor under President Barack Obama's healthcare reform law. Republican leaders in nearly half of the nation's 50 states have rejected the expansion.
The U.S. Department of Health and Human Services now expects 11 million uninsured Americans to obtain coverage next year, down from about 22 million projected a year ago, according to the report, which appeared in the journal Health Affairs...The new report estimates that Medicaid enrollment will increase by 8.7 million people in 2014, nearly all as a result of the Obamacare expansion. Last year, analysts projected that about 20 million people would gain coverage through the expansion alone.

Roughly 260 million Americans (roughly 85 percent) already have health insurance provided by their employers, the government or through individual policies they purchased. In places like Oregon, Colorado, New York, California and other, mostly Democratic states, governors and state legislators accepted the expansion of Medicaid to provide free health insurance for those earning up to 138 percent of the federal poverty (FPL). For those earning between 138 and 400 percent of the FPL, the Affordable Care Act's subsidies will help them purchase private insurance in the so-called health care exchanges.
But as other studies have warned, the numbers left behind in the GOP-dominated states are staggering. In Texas, Governor Rick Perry denounced Obamacare Medicaid expansion as a "fool's errand." But his foolishness in opting out means an extra 1.9 million Texans will needlessly go without health insurance in state where 24 percent of all residents--and 30 percent between the ages of 18 and 64--lack coverage. In Florida, where the GOP legislature rebuffed Republican Governor Rick Scott's choice to accept the windfall from Washington, another million residents will be left uncovered. (In contrast, over 300,000 more Arizonans will gain insurance, thanks to a rare showing of common sense by Governor Jan Brewer.) Next door neighbors Minnesota and Wisconsin provide another useful case study. While Democrat Mark Dayton will be cutting the ranks of the uninsured by almost half in his state, in Madison Republican Scott Walker is leaving an estimated 182,000 folks out in the cold.
Mississippi, that poster child for just about every social pathology imaginable and where former RNC Chairman and Governor Haley Barbour claimed "we have people pull up at the pharmacy window in a BMW and say they can't afford their co-payment," provides a shocking case in point. As the Washington Post's Glenn Kessler detailed:

Mississippi provides some of the lowest Medicaid benefits to working adults in the nation. A parent who isn't working can qualify only if annual family income is less than 24 percent of the poverty line. Working parents qualify only if they make no more than 44 percent of the federal poverty level. Seniors and people with disabilities are eligible with income at 80 percent of the poverty line...
Translated from the federal poverty guidelines, that means a working Mississippi couple with one child could earn no more than $8,150 a year and still qualify for Medicaid, seniors and people with disabilities could earn no more than $8,700, and a pregnant woman could earn no more than $20,000 a year.

The disturbing result in the Magnolia State and other Republican bastions across the nation, McClatchy warned, is a "coverage gap" in which 5.5 million people will be left to fend for themselves:

[The coverage gap is] a bureaucratic twilight zone where people with poverty-level incomes don't qualify for Medicaid and can't get tax credits to help buy coverage on the new insurance marketplaces.

As the AP summed it up, "Nearly 2 in 3 uninsured people who would qualify for health coverage under an expansion of Medicaid live in states which won't broaden the program or have not yet decided on expansion."
Mercifully, the frightening red state health insurance coverage gap likely won't be permanent. As Gigi Cuckler, an economist with the Centers for Medicare and Medicaid Services and co-author of the HHS report explained:

"For the states that do expand, we're expecting that some will elect to expand their Medicaid programs after 2014."

The past several weeks have provided grounds for optimism on that front. In Pennsylvania, GOP Governor Tom Corbett is trying to follow Rick Snyder's leader in Michigan by accepting the Medicaid expansion. As Sarah Kliff detailed two weeks ago, the impact will be significant:

Between Pennsylvania and Michigan, you're looking at more than 800,000 people becoming eligible for new health law programs. And if the Pennsylvania expansion does go through, it would be the 26th state to expand Medicaid, meaning that the majority of states had decided to opt into a massive health law provision that the Supreme Court decision last year accepted.

Ohio's GOP Governor John Kasich wants to join them. He is continuing to press his GOP legislative majority to accept the Medicaid expansion that would cover an additional 366,000 Buckeye State residents, declaring "I believe it's a matter of life and death." As Kasich warned his GOP colleagues in June:

"When you die and get to the meeting with St. Peter, he's probably not going to ask you much about what you did about keeping government small, but he's going to ask you what you did for the poor. You'd better have a good answer."

...While Passing Up Free Money from Washington...
Republicans in those state capitals better have a good answer indeed for why they turned down federal money for the Medicaid expansion. After all, it's virtually free.
The federal government will pay for 100 percent of the cost of the Medicaid expansion until 2017 and 90 percent after that. But the billions the "opt-out" states will have to come up with in future years will be more than offset by their extra costs to compensate hospitals and other providers for the care of the uninsured. As Ezra Klein and Evan Soltas summed up a recent analysis by the RAND Corporation of 14 Medicaid rejecting states:

It finds that the result will be they get $8.4 billion less in federal funding, have to spend an extra $1 billion in uncompensated care, and end up with about 3.6 million fewer insured residents.
So then, the math works out like this: States rejecting the expansion will spend much more, get much, much less, and leave millions of their residents uninsured. That's a lot of self-inflicted pain to make a political point.

As another RAND study predicted, that self-inflicted pain will affect the premiums of other people in the "opt-out" states as poorer, sicker population enter the pool for private insurance. In its report suggesting "No Widespread Increase in Cost of Individual Health Insurance Policies Under Affordable Care Act":

The study also includes an analysis of the effect of Medicaid expansion on premiums in the individual market if Texas, Louisiana and Florida decide not to expand Medicaid under the Affordable Care Act. If this occurs, many more people will be forced into the individual market to buy health insurance. The analysis found that the shift will cause rates in the individual insurance market in the three states to rise by 8 to 10 percent.

...and Putting Hospitals at Risk
And that self-inflicted pain won't just be limited to patients. As Jan Brewer explained her unpopular decision to accept the Obama administration's largesse in expanding Medicaid for 300,000 Arizonans:

"It's pro-life, it's saving lives, it is creating jobs, it is saving hospitals."

Just ask the people who run Georgia's hospitals. Republican Governor Nathan Deal said no to $33 billion in new federal Medicaid funding over the next decade. But as the federal government significantly reduces funding on Disproportionate Share Hospital (DSH) payments for the care of the uninsured, states like Georgia which turned down Obamacare's Medicaid dollars will be on the hook to make up the difference. For Grady Memorial Hospital, the largest in the metro Atlanta area, what could have been an annual boon of $60 million and coverage for 27,000 uninsured patients instead will be a $45 million loss. Georgia taxpayers will have to pay more even as hospitals likely cut services. All because a Republican Governor said "no" to free money from Washington, DC.
In North Carolina, where Medicaid expansion could have reduced the state's uninsured population by a half, small community hospitals are already at risk. As ThinkProgress documented earlier this month:

Residents of Belhaven, North Carolina got a taste of how stubborn GOP opposition to the Affordable Care Act can affect them personally when executives at Vidant Health System unanimously voted to shut down the local Vidant Pungo Hospital within six months. Vidant officials said the move was necessary as a consequence of North Carolina's refusal to participate in Obamacare's optional Medicaid expansion.

The lesson, as Businessweek explained in June, is that Republicans' decisions to forego that Medicaid windfall will have their greatest impact on institutions serving poor and elderly communities:

For-profit health systems whose patients are largely covered by private insurance may be equipped to absorb the losses. Rural and inner-city hospitals that run on thin margins and treat large populations of patients on Medicare, Medicaid, or without any insurance are suffering.

With the nation's emergency room capacity already contracting, the Republican plan echoed by George W. Bush, Tom Delay, Mitch McConnell, Mitt Romney and most recently Mississippi Governor Phil Bryant becomes a crueler hoax every day:

"There is no one who doesn't have health care in America. No one. Now, they may end up going to the emergency room. There are better ways to deal with people that need health care than this massive new program."

No State Exchange Means Not Getting the Word Out...
While Democratic-led states are embracing the Affordable Care Act's exchanges to bring new insurance choices, lower premiums and improved customer service to blue state denizens, the 34, mostly Republican states that refused to run their own exchanges are spending little--and doing even less--to help their residents learn about all of their new options under the Affordable Care Act.

The New York Times documented this latest red-state horror story back in August:

Maryland is spending $24 million on a program that will soon dispatch 325 navigators and assisters around the state. Colorado is investing $17 million on 400 "coverage guides," and New York is spending $27 million on a similar effort.
But in states like Virginia, which declined to build their own insurance markets under the law and ceded the task to the federal government, navigators will not have much money to get the word out. The Obama administration has promised up to $54 million for navigators in the 34 states where the federal government is setting up all or part of the markets. The grants are to be awarded Thursday.

(The total ultimately awarded was $67 million, not $54 million. Even with those funds, the states depending on Uncle Sam to run their exchanges for them will be significantly outspent by their blue state counterparts when it comes to ACA outreach and marketing.)

As the Bush administration learned the hard way with its bungled launch of the Medicare Part D prescription drug benefit in 2006, those customer service "navigators" are absolutely essential. (When the program first went into effect, there were only 300 customer service representatives standing by for the 43 million Medicare recipients.) And as the chart above shows, the gap is staggering. Texas, with six million uninsured--24 percent of its entire population--is spending less ($11 million) on outreach and customer service than Minnesota, where only about half a million currently lack coverage. And as the New York Times revealed in recent profiles of Missouri and Colorado, the red-blue difference in Americans' experiences will be like night and day.
While Colorado is "a hive of preparation, with a homegrown insurance market working closely with state agencies and lawmakers to help ensure the law's success," in Missouri by contrast "looking for the new health insurance marketplace, set to open in this state in two months, is like searching for a unicorn."

While states like Colorado, Connecticut and California race to offer subsidized insurance to their citizens, Missouri stands out among the states that have put up significant obstacles. It has refused to create an insurance exchange, leaving the job to the federal government. It has forbidden state and local government officials to cooperate with the federal exchange.
It has required insurance counselors to get state licenses before they can help consumers navigate the new insurance market.

...and Getting in the Way of the Navigators...
Missouri, which also tried to nullify Obamacare within its borders, has plenty of company in trying to block the navigators, the dozens of community groups, charitable organization, hospitals and non-profits that will help Americans find health insurance now just as they helped the elderly select prescription drug plans during the roll-out of President Bush's Medicare Part D program. Now, Republicans in Ohio, Georgia, Texas, West Virginia and Florida are boasting about the efforts to obstruct navigators in their states. As Georgia Insurance Commission Ralph Hudgens crowed:

"Let me tell you what we're doing [about Obamacare.] Everything in our power to be an obstructionist."
"We have passed a law that says that a navigator, which is a position in that exchange, has to be licensed by our Department of Insurance. The ObamaCare law says that we cannot require them to be an insurance agent, so we said fine, we'll just require them to be a licensed navigator. So we're going to make up the test, and basically you take the insurance agent test, you erase the name, you write 'navigator test' on it."

In that effort, Republicans in the states are getting a lot of help from GOP leaders on Capitol Hill. As The Hill reported on Monday:

Republicans on the Energy and Commerce Committee questioned how navigators will go about the task of explaining new health insurance options.
The most recent letter to the Health and Human Services Department follows an earlier inquiry in which committee Republicans sent exhaustive data requests to many of the organizations that received grants to participate in the navigators program.
Democrats assailed that investigation, saying it was designed to distract navigators just as the law's new marketplaces are about to open.

The Democrats' skepticism is well-founded. After all, many of the same navigators the Bush administration funded during its Medicare Part D launch (like the AARP) are Obamacare navigators now. Ironically, President Bush and his Republican allies also counted on organization that doesn't exist anymore: ACORN.
...While Republican Representatives Refuse to Take Constituent Calls
To help fill the information void, groups like Enroll America are planning to supplement federal outreach in 10 critical, often recalcitrant states including Texas, Georgia and Florida. But when all else fails, Americans can always contact their members of Congress for help. Unless, that is, their representative is among the Republicans who have already announced they won't take any constituent inquiries about Obamacare. As The Hill explained, their answer is "call Obama":

Some Republicans indicated to The Hill they will not assist constituents in navigating the law and obtaining benefits. Others said they would tell people to call the Department of Health and Human Services (HHS).
"Given that we come from Kansas, it's much easier to say, 'Call your former governor,'" said Rep. Tim Huelskamp (R), referring to HHS Secretary Kathleen Sebelius.
"You say, 'She's the one. She's responsible. She was your governor, elected twice, and now you reelected the president, but he picked her.'" Huelskamp said.
"We know how to forward a phone call," said Rep. Jason Chaffetz (R-Utah).
"I have two dedicated staff who deal with nothing, but ObamaCare and immigration problems," he added. "I'm sure there will be an uptick in that, but all we can do is pass them back to the Obama administration. The ball's in their court. They're responsible for it."

Many GOP States Won't Crack Down on Abuses by Insurers
Republican-led states aren't just actively preventing their residents from getting information about the right health insurance option for them and their family. As it turns out, several Republican states plan on giving their people the finger afterwards, too.
That's the word from the Texas Tribune, which reported that in August Texas will join Arizona, Alabama, Missouri, Oklahoma and Wyoming in refusing the guarantee that insurance companies follow the ACA's new regulations:

Though Texas will join 26 other states in defaulting to a federal marketplace for purchasing health insurance -- a major component of the Affordable Care Act -- it is one of only six that will not enforce new health insurance reforms prescribed by the law. It's a decision some say could lead to confusion over who's responsible for protecting Texas insurance consumers.

Among other things, those reforms prohibit insurers from refusing to cover those with pre-existing conditions, using "rescission" to drop coverage for those who become sick, discriminating against women and setting annual or lifetime benefits caps. But because the Texas Department of Insurance claims it lacks the authority to enforce those rules, Texas residents may be "bounced back and forth, which is a burden for consumers." If consumers suspect they are being overcharged or denied coverage, ThinkProgress asked:

But who do you complain to?
Usually the answer is your state's insurance department. But the answer is CMS [the federal Centers for Medicare and Medicaid Services] if you live in one of the six states that won't enforce the consumer protections. Unfortunately, if you don't know that, you could spend months oscillating between the state and federal government, trying to figure out if you're getting hoodwinked by your insurance company. And in the meantime, the bills are piling up.

Kevin Lucia, an assistant research professor with the Georgetown University Health Policy Institute's Center on Health Insurance Reforms, explained that enforcement duties are "typically reserved for state insurance departments." Stacey Pogue, a health policy analyst with the Center for Public Policy Priorities, rejected the notion that TDI's hands are tied, pointing out that in the past the agency has responded to federal laws by "taking actions that ensure that they do have oversight."
The Greatest Disinformation Campaign of the 21st Century
Given the GOP's unprecedented campaign to stop the Affordable Care Act by any means necessary, it's no wonder the American people are confused and concerned. A recent survey by the Pew Research Center found that only 42 percent approve of Obamacare, while 53 percent disapprove. (The latter figure is padded by liberals who lament the law does not go far enough in reforming the American health care system.) While the Washington Post's Sarah Kliff frets, "Americans are very, very confused about the Obamacare," Patrick Brennan of the National Review crowed, "Pew finds people dislike Obamacare so much they might even trust Republicans now."
They shouldn't. Because to first prevent and then to undermine the Affordable Care Act, Republicans engaged in the greatest disinformation campaign of the 21st century.
Consider just some of the GOP's tried and untrue talking points about Obamacare. There are no "death panels." Politifact's 2009 Lie of the Year was succeeded in 2010 by "the government takeover of health care." The ACA doesn't increase the national debt; it actually reduces it. There is no rationing of care. Obamacare isn't a "job-killer" that has prevented 8 million Americans from finding full time work. The lists (for example, here, here and here) go on and on.
But the American public's opposition may not go on much longer. After all, the now-strongly supported Medicare drug program was even more unpopular before its launch than Obamacare is now. With the Congressional GOP's last gasp efforts to delay or derail the Obamacare rollout almost certain to fail, Republican water carriers like the Washington George Will and the Wall Street Journal's Daniel Henninger are left to chant "Let Obamacare Fail" and "Let Obamacare Collapse."
But if a year from now the Affordable Care Act is perceived to have failed, it will be in exactly those states where Republicans have done everything possible to kill it. But more likely, red state Americans will come down with a severe case of "blue state envy," as millions of their friends and family in Connecticut and Colorado, California and New York, Oregon and Maryland and other Democratic states obtain the health insurance they themselves lack. All because the Republicans who represent them decided it was better to be dead and red.
(This piece previously appeared at Dailykos.)


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Jon Perr
Jon Perr is a technology marketing consultant and product strategist who writes about American politics and public policy.

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