“I was about 11 years old.” The United States has the most complex health care system in the world. It’s our country’s immune system, and, like any immune system, it’s not perfect. “My immune system doesn’t know that my small intestine is a thing it should not attack.” That’s Matthew. He lives in Massachusetts, and he has Crohn’s disease. “Stabbing abdominal pain at like two o’clock in the morning. I had imaging done, CT scan, incredibly expensive IV antibiotic therapy. The worst experience of my life. I cannot imagine the stress that going through that experience and not having health insurance would have caused.” Matthew is one of the 70 million Americans — one in five — who gets his health care paid for by Medicaid. “Without Medicaid, without access to really good medical care, I wouldn’t be alive. Medicaid paid for all of those things.” But the thing about Matthew is, if he lived in a different state, he might not have Medicaid. This state-by-state inequality is baked into the Medicaid system, and the American health system at large. We hear all the time that But that’s an average. There are many states that have great outcomes. States where life expectancy, infant mortality, and preventable hospital admissions look like European countries. But not every state. If you look at the states below the US average, those with the lowest life expectancies, the highest infant mortality rates, and the most preventable hospital admissions, they all have something in common. A sizable portion of their population doesn’t have health insurance. Regardless of what you see on TV, the most lifesaving medical care in this country isn’t sexy. It’s the regular medical care you get when you have good, affordable insurance that saves more lives. Most countries around the world improved their citizens’ collective immune system with a universal health program. But America has always been a bit different. “The right to adequate medical care, and the opportunity to achieve and enjoy good health.” FDR’s New Deal to help the US beat the Great Depression in the early 1930s focused way more on unemployment and Social Security than on health care. And there was a reason for that. The American Medical Association, the largest trade group for doctors, lobbied hard against any form of national health insurance whenever FDR proposed it. So he and his administration let it go. And when they did, private insurance companies stepped in. “Private insurance really grew rapidly through the Second World War, because there were federal wage freezes, and there was a labor shortage.” “…to fight this war, ten million more people must go to work by the end of 1943…” “So you’re an employer, and you’re having a hard time hiring people and you’re not allowed to offer more money, so what you do is you sweeten the benefit package. But in other countries, like Great Britain, private, employer-based insurance didn’t really develop. And before it could, the government began offering health care to its citizens through the National Health Service, or NHS. “This new health service will be organized on a national scale, and so everyone will pay for it, and everyone will benefit from it. When you’re ill, you won’t have to pay for treatment.” But not every European country created a single payer system like Britain’s. As in the US, private insurance companies
cropped up in Germany and France, but unlike the US, those countries regulated these companies closely. They had to operate as nonprofits, they had
to cover everyone, and they couldn’t refuse to pay for something. American doctors and insurance companies didn’t want to see this type of system limiting their profits. “The percentage of Americans who had private health coverage just ballooned from about 1938 to 1950. And that’s when doctors started to get rich. The physician community which was very very tight, it had very good organization, just put their foot down and said ‘No.’ ‘Never, never, never.’ President Harry Truman took up the cause again in 1948. “I have repeatedly asked the Congress to pass a health program.” But the American Medical Association spent millions on PR and lobbying, and Truman’s plan went nowhere. In 1961, President Kennedy proposed Medicare, a plan to cover hospital bills for Americans 65 and older and the AMA hired Ronald Reagan, back when he was an actor, to record this ad. “the doctor begins to lose freedoms, and from here it’s a short step to all the rest of socialism…” Then, in, 1964 President Lyndon Johnson won the Presidency by a huge margin. “This administration, today, here and now, declares unconditional war on poverty in America.” As part of this War on Poverty, Johnson pushed Kennedy’s Medicare program through Congress. And tucked into that bill was a small provision hardly anybody noticed. It called for the federal government to give
aid to states to help cover medical costs for the poor. And that was the beginning of what we know today as Medicaid. It’s gone through a number of changes throughout the years, but at it’s most basic level, Medicaid is a health insurance plan for lower-income and disabled adults, and children. “Many of them are children, almost half in some states, more, and some of them are adults who cannot afford private health insurance for a variety of reasons. Unlike the Medicare system, which covers all Americans 65 and older, states can decide who gets coverage and what gets covered in their version of Medicaid. There are a few groups of people the federal government says states have to cover: children and pregnant women in families below a certain income, plus some seniors and people with disabilities. But for anybody else, states get to decide who qualifies. In California, a single person who makes $10,000 a year qualifies for Medi-Cal, the state’s Medicaid program. When they go to the doctor, they show their
Medi-Cal card, and pay a $4 co-pay. If they need a prescription, they pay $4. The doctor sends the bill to Medi-Cal. The State of California pays half, and the Federal government pays the other half. That split varies by state. The federal government would pay a higher
share for the same doctor’s visit in Alabama. Because federal payments are calculated based on the state’s per-capita income But that same person making $10,000 a year, won’t qualify for the Texas version of Medicaid. In fact, if you’re a non-disabled adult with no children, it’s impossible to qualify for Medicaid in Texas. States also get to decide what services get covered by their version of Medicaid. “Whether you get dental coverage, vision coverage, podiatry, physical therapy. Even hospice, end-of-life care. You may not be able to get a hearing aid, you may not be able to get glasses. There are a lot of services that are highly dependent on what state you live in.” One of the goals of the Affordable Care Act was to limit some of this state-to-state variability by making Medicaid available to everyone below a certain income threshold, no matter where they lived. But the Supreme Court struck down that part of the law. “The court is leaving open to the states to come back and opt in to the Medicaid expansion at their discretion.” “31 states and the District of Columbia made Medicaid available to anyone in their state who made less than about $17,000 a year. In exchange, the federal government reimbursed those states for the added cost of covering more people. Some governors in states that didn’t expand Medicaid said they were worried about long-term costs. “We can’t afford it. The state of Alabama will have to pay 700 million dollars through our general fund that we really cannot afford.” “This is not free money. Every dollar we don’t spend on Medicaid is another dollar we don’t have to borrow from China.” Although the federal government was paying 100 percent of the cost of expanding Medicaid at first, by 2020 that share will drop to 90 percent. The Medicaid expansion was paid for by a tax increase, one that only affected the top five percent of income earners. But it is true that Medicaid costs are rising. They made up 10 percent of federal and state budgets 30 years ago, and today that share is more than 25 percent. Part of that increase is a reflection of the rising cost of health care as a whole. Health care spending went from about 9 percent of GDP in 1980 to 17 percent in 2013. Although it’s worth pointing out that increase was much smaller in other countries. Conservatives worry that more people on Medicaid will only increase costs further. “Everyone who qualifies based on a given state’s rules and eligibility criteria is able to get that service, or able to get that benefit, and there’s no cap, there’s no limit to how much the federal government will reimburse states.” In 1995 under President Clinton and then again in 2017, Republicans in Congress proposed changes that they said would make Medicaid more financially solvent. They would do it by giving Medicaid a fixed amount of cash, called block grants, not a guarantee of coverage.” “Block granting basically says, ‘here’s a big
lump sum, and that lump sum you can do with what you want.'” And that’s what Matthew, the Medicaid patient from Massachusetts, worries about. “My particular course of Crohn’s disease is severe and resistant to treatment.” That means the medicine he needs to stay alive is really expensive. “Tens of thousands of dollars per year.” Before he was on Medicaid, he would fight with private insurers who denied coverage. “Cigna claimed to lose certified pieces of mail and not get faxes in order to stall approval. I continued to lose weight. I continued to be dehydrated. I continued to be malnourished. I continued to be in an incredible amount of pain. And losing Medicaid wouldn’t mean he couldn’t go to the emergency room. It would just mean that when he does, he wouldn’t get the same kind of treatment he gets now, and he’d be stuck with thousands of dollars in hospital bills. “Everything that’s happened to me, the dozens of emergency room visits, the surgeries, the months worth of cumulative time spent as an inpatient in a hospital, all of it, could happen to anyone.” And if it does, and you live in the United States, which state you live in can mean the difference between life and death. “We don’t condition public education on being a model student. If your kid flunks Algebra 1, they aren’t kicked out of school. They get to take Algebra 1 again. If someone’s sick, they’re not morally bad. They’re not morally wrong. They just need health care.