For the second time this year, voters in a Republican-run state chose to expand Medicaid to cover adults earning up to 138% of the poverty level. Missouri estimates nearly a quarter-million low-income people will soon join its program.
The vote wasn’t close. Over 53% of voters approved the measure. The victory came despite President Donald Trump leading the presidential race in the state by 5.9 percentage points as of Aug. 6, according to the latest FiveThirtyEight polling data.
It also came over the opposition of Gov. Mike Parson, who moved the referendum from its originally scheduled November date to primary day, when only a third of registered voters typically turn out. Missouri is also one of 17 states challenging the constitutionality of the Affordable Care Act, a case now before the U.S. Supreme Court.
It’s increasingly clear that a majority of Americans have grown weary of the never-ending battle over health insurance coverage. Given the rising number of uninsured from the nation’s uncontrolled COVID-19 pandemic, they are in immediate need of pragmatic solutions for expanding coverage.
In the short run, expanding use of the ACA’s options is the only path for shoring up coverage. Medicaid managed-care companies report enrollment grew 5% to 7% in recent months after states, responding to the second coronavirus relief bill, stopped eligibility redeterminations. Those reviews force some off the rolls when their incomes rise, even if they are still living in poverty and don’t have employer-based coverage.
The Medicaid rolls are likely to grow in the coming months. More people will lose employer-based coverage as states reimpose lockdowns to contain the virus.
Expanding use of exchange-based ACA plans will be harder. The Trump administration has done almost everything in its power to undermine enrollment. Its 2017 tax bill killed the individual mandate and the penalty for going uninsured, encouraging millions of healthy people to forgo coverage. HHS curtailed marketing, cut funding for navigators, and ended grants to not-for-profits that help people sign up.
To discourage use of exchange plans, HHS is promoting use of skimpy, non-ACA-compliant plans that leave people with enormous healthcare bills when they get sick. The administration also expanded those plans to 12 months duration, up from the three months previously allowed.
HHS also shortened the open-enrollment period. Then it added new requirements for people who seek to enroll outside open enrollment because of a life-changing event—like suddenly becoming unemployed in a pandemic.
No wonder 1.3 million fewer people signed up for exchange plans in 2020 compared with 2016. Despite steady pre-pandemic economic growth, the uninsured rate rose from 10.9% just before the 2016 election to 13.7% at the end of 2018, according to Gallup polls. It’s undoubtedly higher now.
The Trump administration and Republican-run Senate still have no plan to address the coverage crisis. The Republican National Committee website says there will be no update of their 2016 platform, which had no replacement plan in its call to repeal the ACA.
If elected, former Vice President Joe Biden promises to change many of the rules that discourage enrollment; add a public option to the exchanges; and open Medicare to people at age 60. Since those moves require new legislation, government rulemaking or executive orders, voters opting for change shouldn’t expect much from a new administration until February or March at the earliest.
Congress can still avert an expanding coverage crisis this winter. In the stimulus package under consideration, it could add new aid to states to expand Medicaid. It could make it easier to sign up for ACA plans and make them more affordable to the un- and under-employed.
It could do something.