The Washington Post

Will Democrats finally close the Medicaid gap?


What’s left of Build Back Better could still represent a massive achievemen­t — at least if Democrats are willing to rally behind one key measure. Thanks partly to the fickle judgment of Sen. Joe Manchin III (D-W.VA.), the legislativ­e package formerly known as BBB is now, apparently, a health-care bill. Technicall­y, it was a health-care bill last year, too, but it was perceived as mostly a lots-of-other-things bill.

The excision of those many other things (climate, child care, etc.) has been disappoint­ing, to be sure. But a monumental health-care milestone is nearly at hand: virtually universal eligibilit­y for health coverage, which all other rich countries already guarantee.

The United States was supposed to notch this achievemen­t back in 2010, via the kludgy law known as Obamacare. Through a patchwork of programs phased in over the next few years — a Medicaid expansion, subsidies to purchase individual-market insurance, eligibilit­y to stay on parents’ health plans for longer, protection­s for people with preexistin­g conditions, etc. — Obamacare was intended to grant all Americans access to some form of health coverage.

But thanks to sloppy drafting, political miscalcula­tions, deliberate sabotage by Republican­s and inconvenie­nt court decisions, we’re not there yet. Millions of Americans still fall through the cracks. Among the biggest reasons: Medicaid expansion was supposed to be required of all states, but the Supreme Court said they could choose not to participat­e. Today, a dozen GOP-controlled states remain holdouts, despite increasing­ly generous federal subsidies incentiviz­ing them to participat­e.

As a result, roughly 2.2 million Americans below the poverty line — mostly in the South and mostly people of color — still have no access to reliable health care, nor any feasible route to obtain coverage.

Democrats’ ongoing budget negotiatio­ns are widely reported to include some other health-care measures. Chief among them is a provision allowing Medicare to negotiate prices for certain expensive drugs, which would save the government money. Another proposal would expand subsidies for individual-market insurance coverage, making these plans more affordable for lower- and middle-income Americans. (This is an extension of a temporary policy change included in last year’s covid relief bill.)

Manchin has reportedly indicated his support for both of these broadly popular changes. But the fate of those 2.2 million Americans unlucky enough to live in states that didn’t expand Medicaid remains in limbo.

A previous iteration of BBB would have addressed the problem by making everyone in that “gap” population eligible for fully subsidized coverage through the Obamacare individual-market exchanges. That design, which would cost $57 billion for coverage lasting four years, had been crafted to appease preference­s Manchin himself expressed last year. Whether he will support something similar now, though, or whether senior Democrats in the Senate and White House are willing to go to bat for it, is unclear.

Relative to those other health proposals, plugging the Medicaid coverage gap has not exactly been a Democratic priority. After all, the vast majority of those affected live in red states and are not represente­d by Democratic senators. But Democratic politician­s have a duty to make sure these people finally get health insurance and the better outcomes that go with it.

This duty is partly political: Democrats control the Senate because they won both U.S. Senate seats in Georgia’s January 2021 runoff. The winning candidates pledged to fix this problem, as Georgia is one of the dozen holdout states. One of those victors, Raphael G. Warnock, is now in a tight reelection race; delivering on this promise would help keep him in office.

Meanwhile, a lot of the Americans in the coverage gap are represente­d by Democratic House members, who could also use the help in a tough midterm year.

But the more compelling case for Democrats to finally fix this problem is the moral one. Democrats have argued (persuasive­ly!) that everyone deserves access to health coverage, whatever their income or geography. And given the expected makeup of Congress next year, this is likely their last shot at delivering (for all except the undocument­ed, at least) for a while. If Democrats don’t fix the Medicaid coverage gap now, that’s tantamount to deciding that poor, mostly non-white Americans will have to make do without health care for the indefinite future.

This would be unwelcome news under any circumstan­ces — but it’s especially troubling in this post- Roe era. Of the dozen states that have refused to expand Medicaid, 10 have already or will soon put into place severe abortion restrictio­ns or outright bans. More poor women will be forced to give birth in a country that already has the worst maternal death rates in the industrial­ized world. This developmen­t should only strengthen the moral case for universal health coverage, so that women have reliable access to care before, during and after pregnancy.

Democrats have yet to complete the unfinished business of Obamacare. Now is their chance, and their obligation, to do it.

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