Now that the Supreme Court has left the fate of the Affordable Care Act hanging another few days, it seems an opportune moment to pose a question that has been growing on me after several recent reporting trips: why aren’t the most obvious beneficiaries of the law more aware of it?
There is an assumption in much national coverage of the law’s unpopularity that the right has won the “messaging war” on the law, partly, as Abby Goodnough lays out in a strong New York Times piece today, by spending far more to bash it on the airwaves than the law’s supporters have to defend it. There’s also an assumption that many in the white working class who will benefit from the law are sharply opposed to it because they, well, don’t much care for the guy who signed it into law. Both of these things are no doubt true. But my reporting leads me to think that the problem, to a large extent, gets to a very specific issue: the decision by the administration not to broadcast the part of the law that will have the most obvious, immediate impact on the working class: the expansion of Medicaid.
At least half to the expanded health coverage in the law—an estimated 16 million people—is to come through bringing Medicaid eligibility, in 2014, up to a national threshold, 133 percent of the poverty level (about $31,000 for a family of four.) The impact is going to be especially big in states of the South and West that now have exceedingly stingy eligibility rules—in Texas and Virginia, among others, earning as much as $10,000 a year disqualifies even a parent of small children from getting covered; if you’re childless, forget about it.
But when was the last time you heard the administration talking up this massively consequential part of the law? To the extent it does try to promote the law, it’s all about the filling of the donut hole for the Medicare drug benefit, letting young people stay on their parents’ insurance until age 26, credits to small businesses, and new rules on preexisting conditions. All important elements, but none as significant as the Medicaid expansion.
Well, it’s not hard to understand why the Medicaid part of the law was played down. It’s a pure expansion of the public safety net. Whereas the rest of the coverage expansion is, as Obama likes to stress, based on the private sector—by providing subsidies for people further up the income ladder to purchase private coverage—the Medicaid expansion is simply adding a lot more people to the rolls of a government insurance program (although in many states, Medicaid is contracted out to private HMOs, an increasingly lucrative sector for insurers). Moreover, emphasizing the Medicaid expansion would only draw more attention to the bewailing by governors (mostly Republican, though not all) about the burden that the expansion will add to their budgets—never mind that the cost of the expansion will be picked up almost entirely by the federal government, an outrageously good deal for the aforementioned “stingy” states that will be paying far, far less to cover the working poor in their states than the more generous states will be paying for their share of Medicaid costs.
So yes, I grasp on one level why it's been hush-hush on the Medicaid expansion. But it's also greatly disheartening to come across the consequence of this hush-hushness: people who will directly benefit from the expansion who have not a clue that it is coming. In Ohio, I met Columbus resident James Tichenor, a 50-year-old McDonald's employee without health insurance:
A van missing a wheel sat jacked up on the driveway; an armchair lay on its side in front of the house; a 16-month-old boy, the son of Tichenor’s deceased niece, cried inside the house. Bruskin forged ahead, taking it in stride when Tichenor said he had no e-mail address (“I don’t know nothing about computers”) and that he could not give any money (“Right now, I’m pretty well busted”). He told me he wasn’t sure who he was voting for. I asked: Wouldn’t Obama’s health care law help him? He shook his head, saying he couldn’t afford the $51 per week bare-bones health plan offered by McDonald’s. I told him I was pretty sure that, if his employer didn’t offer decent, affordable coverage, he would qualify for Medicaid, which Obamacare will greatly expand. He said he’d never heard anything about that: He worked nights and didn’t watch the news.
In Tennessee, I met countless people who will qualify for Medicaid but knew nothing of this, including Robin Layman, a 38-year-old mother of two who lost her Medicaid coverage last fall, the day she returned from a week in a psychiatric hospital after a suicide attempt, and hasn't been to a psychiatrist since because she can't afford it, and who is also petrified that her 18-year-old son, who is still dealing with major surgery after being hit by a speeding driver two years ago, will soon age out of Medicaid. "What new law?" she said when I told her about the Medicaid expansion. "I've not heard anything about that."
So: the next time you hear pundits talking about how voters don’t like Obamacare, keep in mind: not only are many voters getting bad information about the law, many of them are getting zero information about the law.
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