"Medicaid expansion is the jewel of the ACA"
As Trump gleefully forecasts -- and thereby threatens to trigger -- the implosion of the ACA marketplace, methinks Democrats are starting to emotionally decouple from it. "You break it you own it" is a preemptive strike in messaging -- and potentially, a step toward planning the next phase when Democrats are in a position to shape public policy.
The AHCA's double-barreled assault on Medicaid -- repealing the ACA expansion and imposing per capita caps -- helped Democrats to see the ACA whole. Hours before the bill hit, Andy Slavitt provided some clarity:
When #ACA replacement bill is out, don't get distracted by exchanges.
The big issue is dramatic cuts in Medicaid to pay for huge tax cuts.— Andy Slavitt (@ASlavitt) March 6, 2017
Now enter Harold Pollack, who has a granular sense of how Medicaid functions in U.S. society, chronicling how Republican governors' support for the ACA expansion helped sink the AHCA. Pollack, like Slavitt, reframes the ACA -- at least in public discussion forever obsessed with the private plan marketplace:
In political and human terms, Medicaid expansion is the jewel of the ACA. Within the states that embrace it, Medicaid expansion is the most important public health advance in decades.
Medicaid, Medicaid...made in the shade with a garden spade. Better yet once ACA'd...
More startling still is Pollack's conclusion:
The more ACA marketplaces falter, the more pressure will build for their replacement, which is surely an expanded Medicare or Medicaid role. If Democrats ever succeed in enacting such a public option, Republicans will quickly feel powerful incentives to join that effort, just as they felt powerful incentives to defend Medicaid expansion.
That's very much in keeping with what UMN professor Larry Jacobs told me this week about the way progressive thought is trending:
The public-private plan was seen as a way to build broad-based support, That's clearly not happened...What did Democrats get in terms of building long-term support for what was intended to be a more moderate approach as compared to single payer or the public option? They didn't win any Republican support for it, and it proved quite difficult to administer."
For the public option to have a major impact, I suggested, it would have to be a "strong" one -- by which I meant probably paying Medicare rates to providers.
"That's what I'm hearing," Jacobs responded. "I don't think it's formed yet, obviously people are focused on the immediate situation. But when I'm involved in conversations about what's next, it's not about going back to Hillary Clinton's agenda [mainly subsidy boosters in the ACA marketplace]. I think the last three months -- plus the last seven years -- are really leading to some new redirection and new examination."
From the opposite end of the political spectrum, Trump buddy Christopher Ruddy has urged further Medicaid expansion on Trump. As I pointed out within days of Trump's election, that is the only way to fulfill Trump's promises to delivery affordable, low deductible health insurance to everyone.
Too bad Trump's promises aren't worth a bottle of Trump Network vitamins. But Democrats' day will come, if our political system survives Trump. And when it does, various forms of public insurance for those who currently must rely on the individual market will be in play.