As we approach the November 6th midterms, one of the core issues for most voters will be healthcare. There is tremendous confusion among the electorate about healthcare. All that people know is that their healthcare costs keep going up and that they want someone to fix it or at minimum someone to blame for it. The following paper gives some history and tries to help the average person make sense of Medicare, Medicaid, The ACA aka Obamacare, single payer, and so much more.
Medicare and Medicaid are two distinct, government-run programs that were created in 1965, under President Lyndon B. Johnson. Included in his “Great Society” Reform package, Medicare and Medicaid emerged as programs to address the inability of older and lower-income populations to attain private health insurance. Under this social commitment, Medicare and Medicaid are intended to be social insurance programs that allow the financial burdens of illness to be shared among healthy and sick individuals, and affluent and lower-income families. The key differences between Medicare and Medicaid are that they primarily serve different populations and are run and funded by different parts of the government.
1. What is the difference between Medicare and Medicaid?
Medicaid is a federal program administered at the state level, meaning each state independently decides how to allocate funds and structure services within federal guidelines. For instance, in the state of Georgia, our Medicaid is distributed primarily by The Department of Community Health and PeachCare Kids. Regarding eligibility, Medicaid covers populations states define as low-income (in general, $41,560 per year for a family of three), regardless of age. Medicaid is intended to cover basic health care costs, including doctor visits, hospital stays, even eyeglasses, and may also cover nursing home care (at certain facilities).
Medicare is a federally administered program uniformly across the United States. Medicare benefits, which are paid from a trust, (if you pay taxes, you’ve been paying in to it since that first paycheck) kick in, regardless of income, starting at age 65 (if not earlier in the case of disability covered by social security, such as autism or loss of vision, among many others).
2. What is the ACA? How does it differ from Medicaid?
The ACA, affectionately known as “Obamacare”, provides individual, private insurance plans that are sold on health insurance exchanges. The ACA plans are offered by health insurance companies such as Aetna, Blue Cross, and Cigna, and must comply with governmental regulations. Conversely, Medicaid is a government-run, social welfare program.
A cornerstone of the ACA is the expansion of Medicaid eligibility, which includes people with annual incomes below 138% of the federal poverty level. Other differences in ACA and Medicaid include a limited enrollment period to enroll in a health care plan under the ACA, which will have a delayed start period, versus the ability to enroll anytime in Medicaid, with immediate, and at times, retroactive, coverage. Regarding cost, Medicaid has little to no cost associated with care, as it is intended for those with very low incomes. ACA plans come with deductibles, copayments, and coinsurances. Another key difference between Medicaid and the ACA plans are that if you are eligible for both Medicare and Medicaid, you may combine the benefits. With ACA plans, it is illegal for a private insurer to sell you an individual market plan after you’ve become eligible for Medicare-- just be sure to cancel your private plan!
3. What’s the deal with this “Medicaid Expansion” I keep hearing about? What has happened (or hasn’t happened) in Georgia with that?
As previously mentioned, a major part of the ACA is the expansion of Medicaid eligibility, to include people with annual incomes up to 138% of the poverty level, ($28,676 per year for a family of three and $16,753 per year for an individual in 2018). Furthermore, the expansion aims to expand coverage to uninsured veterans, Native Americans, and provide earlier coverage to those with HIV.
However, since Medicaid is a state-run government program, not every state is choosing to participate in the expansion. This was upheld by the June 2012 Supreme Court ruling stating that complying with the expansion of Medicaid stipulated within the ACA is optional. Therefore, there are differences in coverage and criteria across state lines. As of 2018, 19 states have chosen not to expand Medicaid-- including Georgia.
To make matters more complicated (and worse), the lack of uniform approval of Medicaid expansion has created a coverage gap in many states, including Georgia, targeting many of the poorest citizens. When policymakers wrote the ACA, they assumed complete coverage of the states. Consequently, they failed to set up other means for the most vulnerable populations to obtain further coverage under subsidies.
For instance, in Georgia, about 240,000 residents make too little to receive financial aid to buy health insurance on the Marketplace, do not currently qualify for Medicaid, and lack any affordable health insurance options. Georgia’s uninsured rate is currently 15.5, and rural Georgia is suffering the most with hospitals closing, only exacerbated by umet mental health needs and opioid abuse.
A new report by the Urban Institute indicates Medicaid expansion in Georgia could provide health insurance coverage for 473,000 Georgians. Not only would the expansion increase healthcare coverage, but it would provide funding to support struggling hospitals, create jobs, and bring in $3 billion from the federal government to support these initiatives. However, as of now, Governor Deal and state Republican leadership have decided that adopting the Medicaid expansion would be too costly to the state-- $136 million a year. Can Georgia afford it? Sure! But, state leaders have allocated spending tax dollars in other ways, such as $309 million for insurance company tax breaks. So if ever you wanted to complain to someone about the lack of Medicaid expansion in Georgia, you can talk to your state representatives in the Georgia General Assembly, but we’ll get to that in a couple of paragraphs.
4. What’s all this talk about coverage for pre-existing conditions?
A monumental provision under the ACA is that health insurers can no longer charge more or deny coverage to your or your child because of a pre-existing health condition. Moreover, once you have insurance, they cannot refuse to cover treatment for any pre-existing conditions or a health problem that occurs once your health coverage starts.
And that’s great news!
But…..
The Trump administration’s latest attack on the ACA may jeopardize protections for pre-existing medical conditions for millions of Americans with coverage through their employer. Attorney General Jeff Sessions has stipulated that the Justice Department will no longer defend provisions that protect people with pre-existing conditions who have insurance through their employers, particularly those through small businesses or corporations and within the legal field. He has further removed the Obama-era requirement to hold health insurance.
Furthermore, at the state-level, protections for pre-existing conditions are imminently under fire, creating uncertainty for constituents. Led by Republican Attorney General of Texas, Ken Paxton-- who is under felony indictment for alleged securities fraud-- 20 States AG’s (including Georgia’s very own Chris Carr) have joined a suit, charging Congress’ changes to the law in last year’s tax bill rendered the entire ACA unconstitutional. If they prevail, according to the Department of Health and Human Services, as many as 130 million Americans with pre-existing conditions could lose healthcare. Currently fighting in opposition, California Attorney General Xavier Becerra, joined by 16 Democratic AGs, has filed a motion to intervene in the lawsuit.
5. I keep hearing about this Medicare for All platform that progressives are pushing? What is that? Will it ever happen?
Medicare for All is essentially a massive expansion-- or replacement-- of Medicare. It would create a federally administered, single-payer health care program. As a patient, all of your health care would be covered: from preventative and emergency care to prescription medications and long-term care. This system would function to normalize rates, spending and coverage, as well negotiate fair prices on prescription medications.
This plan would potentially be funded by a re-appropriation of current tax allocations, graduated taxes on employers, households, as a progressive income tax structure, which addresses various aspects and grievances within our current tax structure. Though the structure, in one proposal, would cost taxpayers $1.38 trillion a year, a recent study by the Libertarian Mercatus Center demonstrated, the plan could lower total healthcare spending $303 billion over 10 years.
So will it ever happen? Not unless we show up to vote to make it possible.
6. What’s this “single payer option” I keep hearing about?
Did you read the above regarding “Medicare-for-all”? It’s similar.
With that said, “Medicare for All” is not exactly an accurate description of the single-payer system. Medicare utilizes both premiums and copays, while single-payer options propose getting rid of this. Medicare depends on lifetime contributions, similar to Social Security, but single-payer is available to everyone, including those who haven’t paid into the system-- aside from taxes. By and large, single payer proposals eradicate the private insurance component, as well as the other lettered classifications, of Medicare described earlier. Furthermore, single payer would cover every medical service across the spectrum.
Interestingly, though similar, the ideas of the two plans poll very differently. A recent poll among democrats demonstrated the term “Medicare-for-All” elicits a more favorable reaction than “single-payer”, with the latest Kaiser Family Foundation health tracking poll noting 53% of Democrats were “very positive” about Medicare-for-All verses only 21% who felt that way about a “single-payer national health-care system.” Language is very important, especially moving forward, therefore, Medicare already being a very popular and well-known program may be aiding its positive responses in the polls.
7. How have/will the Trump administration policies (Tax Cuts and Jobs Act) affected funding for Medicare and Medicaid?
Trump’s ever popular Tax Cuts and Jobs Act does not positively impact Medicare and Medicaid. Republicans have recently passed a budget that will cut nearly $1.5 trillion from Medicare and Medicaid to pay for Trump tax cuts. By 2028, reforms dedicated to cutting payments to providers and reducing wasteful treatment without limiting access to healthcare, will effectively cut Medicare spending by 7.1%. Worth noting, the ACA in 2010, included similar plans and goals. However, by 2028, there is an expected 22.5% cut to Medicaid and ACA subsidies by repealing and replacing the ACA and associated provisions.
Some Republicans argue that economic growth will pay for the Trump tax cuts, so there would be no reasons to cut social programs like Medicare and Medicaid. Other Republicans, like Paul Ryan insist Medicare and Medicaid are, “the big drivers of our debt.”
So, social programs head to the chopping block while the top 1% get a massive tax cut, equating an average of $129,000 a year per top-percenter. But the bottom 80% are rewarded as well, for they will save between $50 and $450 in taxes per year!
8. What can be done at the federal, state, and local level to better my healthcare options? Who do I call? What do I say?
Let your voice be heard! Go to meetings; register yourself, friends, and family to vote; call your representatives, and use the resources here.
Need a script? Try this one by Indivisible regarding Trumpcare (AHCA: American Health Care Act) and proposed ACA repeals:
Caller: Good morning/afternoon! Can you let me know Rep. ______’s position on the American Health Care Act and the Upton proposal?
Option 1: If your Rep. opposes the AHCA
Staffer: Thank you for calling. Rep. ______ opposes this legislation.
Caller: That’s great! Please tell Rep. ____ thank you for opposing the bill. I’d like to hear him/her speak out in the media or on the House floor against repeal of the Affordable Care Act. She/he needs to make it clear that she/he wants to protect people with pre-existing conditions, those on Medicaid, and everyone else who depends on the Affordable Care Act for their health and wellbeing.
Staffer: I will certainly pass on your message to Rep. ______.
Caller: Please do. This is extremely important to me and I will be watching closely for her/his public statements in opposition. Thank you for your time.
Option 2: If your Rep. supports the AHCA
Staffer: Thank you for calling. Rep. _____ supports AHCA and the latest proposed changes.
Caller: I’m very disappointed to hear that. This bill would take away health care from millions of Americans, would cut the Medicaid program, and give $600 billion in tax breaks to the wealthy. With the proposed amendments, states could get rid of protections for people with pre-existing conditions. Money for high-risk pools that segregate the sick into to higher-cost plans will not solve this problem.
[I/my family member] am at risk of losing [my/his/her] insurance. [I/ my family member] have a pre-existing condition that before the ACA could be used by insurance companies to discriminate against me. My health depends on Rep. ____ voting against the American Health Care Act.
Staffer: I will certainly pass on your concerns to Rep. _________
Caller: Please do. This is extremely important to me and I will be watching closely. Thank you for your time.
Option 3: If your Rep. dodges or has no opinion on AHCA
Staffer: Thank you for calling! I’m not sure if Rep. _____ supports or opposes the American Health Care Act at this time, but I’m happy to take down your concerns.
Caller: I’m disappointed to hear that and would ask Rep. ______ to oppose this bill.
Here are my concerns. This bill would leave millions more uninsured and cut Medicaid for the most vulnerable. And importantly, these new proposed amendments still undermine critical protections for people with pre-existing conditions.
[I/my family member] am at risk of losing [my/his/her] insurance. [I/ my family member] have a pre-existing condition that before the ACA could be used by insurance companies to discriminate against me. My health depends on Rep. ____ voting against the American Health Care Act.
I expect Rep. _______ to publicly state his/her opposition to this destructive bill and prioritize the health and wellbeing of his/her constituents.
Staffer: I will certainly pass on your concerns to Rep. ______.
Caller: Please do, and please take down my contact information to let me know when Rep. ______ has made up his/her mind. I’m eager to hear what he/she decides.