Normally, I would find the breathless coverage of Obamacare sign-up numbers superficial and vapid. Over the past few days, it has verged on horse race style coverage that we expect from coverage of political races, chronicling every upward tick in state enrollment numbers and every traffic burst on Healthcare.gov.
But there is something admittedly satisfying about watching the law’s enrollment numbers meet (or maybe exceed) expectations in the closing hours. For a law that has been under siege from its inception, this is a moment of vindication. Obamacare now has a number to put on its constituency – a measure of the social good that it is achieving. The “silent plurality” that liberals wanted to reach now have their moment of recognition, unassumingly putting the noisy opposition that has relentlessly attacked the law on its heels.
Early estimates report that the law has spread health insurance to over 9.5 million previously uninsured Americans – through health insurance marketplaces, Medicaid expansion, and through children under 26 staying on their parents’ health insurance. This is a tremendous accomplishment, but is little more than a solid start in providing coverage to the estimated 45 million Americans that were uninsured before marketplaces went live.
A big reason for this shortcoming is that nearly half of all states have refused to expand their Medicaid programs. Obamacare asks states to expand their Medicaid programs to cover people earning up to 133% of the poverty live. In 2012, however, the Supreme Court made this expansion wholly optional (with no consequences) for the states. This greatly weakened the law’s ability to penetrate states with the highest rates of uninsured. As Alec MacGillis explains, “[n]o one really wanted to say this during the law’s drafting, but its underlying goal was to get coverage to people in red states where there was no local political will to address the problem.”
The states with the gravest insurance coverage crises tend to be red states with skimpy Medicaid eligibility, but are governed by conservatives with deep political opposition to conforming with Obamacare. The law, then, has been unable to reach the populations that need it most. For example, in Texas, Medicaid eligibility is limited to parents making no more than 19% of the poverty line. That’s a mere $4,531 per year. If Texas agreed to expand Medicaid, over one million people would gain health insurance. But with Texas steadfastly refusing to do so, these people fall into the law’s “coverage gap”: too poor to receive the law’s marketplace subsidies, too “rich” (if we can honestly call making 20% of the poverty line “rich”) to join Medicaid – but mostly too cursed by geography. The people stuck in the coverage gap have therefore received absolutely no benefit from Obamacare.
There is no morally defensible reason to refuse to expand Medicaid. Conservative governors warn of future burdens on state budgets and excessive federal control. Yet the expansion is fully funded by the federal government in its first years, and 90% federally funded from 2020 and beyond.
Perhaps more states will come around to accepting a free offer of expanded health insurance for their poor and near-poor populations. The Obama administration has been amenable to compromise solutions from states like Arkansas that want to use Medicaid funds to enroll low-income people in private insurance plans. But some states like Texas will likely remain intransigent for the foreseeable future, neglecting the interests of the politically marginalized uninsured. National uniformity is sacrificed as a consequence of the cooperative state-federal structure of Medicaid.
Obamacare’s enrollment numbers are a great achievement, but we have more work to do in achieving health care justice for all. Specifically, we need to continue to cultivate an ethic of solidarity around health insurance and to cast into moral isolation those who reject the imperative of providing health insurance to the poor. Obamacare does a great job of starting us down this road, but we still have far to travel to reach the rest of the 45 million.