Celebrate or Condemn Enrollment Success? Affordable Care Act Critics Can’t Decide

By Adam Searing, Georgetown University Center for Children and Families

Health care policy debates can often be confusing but the rapidly shifting positions in the latest tempest on Medicaid and the Affordable Care Act are harder to follow than a ping-pong ball.

For background one has to travel back to 2013 as major glitches in the healthcare.gov website were adversely affecting initial enrollment in the ACA. ACA opponents pounced and attacked the law for signing up too few people.

Back then Texas Sen. Ted Cruz complained that only “106,185 Americans have signed up for Obamacare meanwhile millions have lost their insurance because of Obamacare.” And North Carolina’s Rep. Renee Ellmers called enrollment numbers “pathetic.” Some groups opposed to the ACA went even farther and actively urged people not to sign up for health coverage, running advertisements in multiple states urging viewers to “opt out of Obamacare.” Publications like the National Review editorialized that “Young People Should Say No to Obamacare.” And stories in outlets like Fox Business speculated on the failure of the law as “early sign-up numbers show this demographic [young people] isn’t flocking to the exchanges.”

Now fast forward to 2015 but don’t take your eye off the ball.

In a strange twist, opponents of the Affordable Care Act are attacking the law for signing up too many people. The most notable politician pushing the “too many people are signing up” line is Florida’s Governor Rick Scott who is locked in a budget battle with Florida’s Republican-controlled legislature over the merits of accepting federal Medicaid expansion funding. Scott complained recently that, “the growth in Medicare costs, Medicaid costs, it’s always multiples.” Also count on groups opposed to the ACA who now complain that large enrollment numbers mean “that’s twice as much money that’s being added to the national debt.” That particular claim gets a double fault as the Congressional Budget Office has made it abundantly clear that repeal of the ACA – including the state Medicaid expansions – would add to the deficit rather than reduce it since the revenue changes in the ACA would be repealed along with the coverage expansions.

And indeed, the latest federal enrollment numbers show the success of the Affordable Care Act’s enrollment effort in bringing health care coverage to the lowest-income Americans: over 12 million people enrolled in Medicaid since July of 2013. Of course, most of this enrollment growth is taking place in states that chose to expand their Medicaid programs under the ACA and where the federal government is currently funding 100% of the expansion cost. This federal financing will start to decrease after 2016 but will never go below 90%. In states that have expanded Medicaid this increase in enrollment is having significant impacts. The average uninsured rate has dropped to 18.2 percent – a 40% drop. Hospitals in these states are seeing an average of 30% declines in uninsured people walking into their emergency rooms needing health care.

Given the complaints from ACA opponents in 2013 about low enrollment, one would expect that success in enrollment – especially in the harder to enroll low-income population – would be met with approval rather than more attacks. But in the upside down world of health care debate around the Affordable Care Act success becomes not a cause for celebration but one more reason to oppose health coverage for more people.

In short, now that the ACA opponents’ original objection of too few people signing up for coverage has been addressed they have shifted to the argument that too many people are signing up – and we can’t afford it.

And even if these ACA opponents respond that when people enroll in the state health marketplace and are assigned to a Medicaid plan are somehow different than people assigned to another health plan, they wouldn’t get very far. Most states use private health insurers to cover people on Medicaid and these are often the same private health insurers providing health coverage in the state health exchange. Add to that the fact that over 80% of people buying coverage on the state exchanges are getting a federal subsidy in the form of tax credits and the argument disappears even further. People living and working in poverty need health coverage as well, it’s just that the effective federal subsidy for this coverage through Medicaid is more because they can afford to pay less.

In the end, this latest debate around Medicaid and the Affordable Care Act shows once more that ideology trumps good health care policy again – at least for some. Significant progress in meeting health coverage goals that have eluded policymakers for over a century is taking place and Medicaid for the lowest income Americans is a huge part of this success. Because of Medicaid, financial security and better health are now available to 12 million of our fellow citizens where there was no such option before. This shouldn’t be a reason for opposition but rather another marker of success.

Editor’s Note: This is a lightly edited version of a post originally published on the Center for Children and Families’ Say Ahhh! Blog.

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