This week’s New England Journal of Medicine includes a study of the impact of expanding Medicaid coverage to more poor, uninsured adults under the age of 65 years. Comparing states that expanded their Medicaid coverage with surrounding states that did not, the Harvard School of Public Health researchers–Benjamin D. Sommers, M.D., Ph.D., Katherine Baicker, Ph.D., and Arnold M. Epstein, M.D.–reported that expansion of Medicaid eligibility is associated with reduced mortality, a 25% increase in Medicaid coverage, 15% lower rates of uninsurance, a 21% reduction in cost-related delays in care, and a 3% increase in self-reported excellent or very good health.”
This study is quite timely. The Affordable Care Act sought to require states to expand their Medicaid coverage or states would lose federal funding for their existing Medicaid program.In June, the Supreme Court ruled that the federal government’s policy was coercive and thus unconstitutional. Some states will participate in the expansion, but six Republican governors of other states have announced that they will not do so.
Why would a governor not want to expand health insurance coverage to poor, uninsured adults? Budgetary constraints are a major reason, though the federal government would be paying all of the initial cost of expansion and then 90% of the cost by 2020. But it seems that politics and values are another reason. The uninsured may simply not be a concern to some policymakers.
Today, NPR’s Julie Rovner reported on the GOP’s reframing of their opposition to the Affordable Care Act that probably is closer to the truth of the conservative position on expanding health insurance coverage to the uninsured. Their arguments include Senate Minority Leader Mitch McConnell’s (KY) telling Fox News Sunday Program anchor Chris Wallace that covering the uninsured “is not the issue” and that the U.S. already has “the finest health care system in the world.” And Orin Hatch (UT) told the American Enterprise Institute that conservatives “cannot succumb to the pressure to argue on the Left’s terms.” What is the new conservative frame? “Reducing cost and expanding individual liberty,” according to those Rovner interviewed.
In the mid-1970s, I studied public health and medical care in Norway and was struck by how different that country’s values were from those of the U.S. It was clear to me that Norwegians valued community and safety net policies that could prevent the less fortunate from falling into the abyss of poverty with its associated adverse health and social outcomes. Our nation’s preoccupation with individualism often gets in the way of supporting policies that would have us all contribute to safety nets for our neighbors–and ourselves, if we are unlucky enough to need them at some point.
Improving access to health care in the U.S. is not simply a matter of providing insurance coverage for everyone. The issue is much more complex. But we can start with a commitment of ensuring that everyone in the U.S. is able to access health care services that promote and restore health. Any attempt to reframe the discussion of reforming health care must start with what we value and why. Empty rhetorical slogans will not suffice.