726 Days of perspective

Yesterday, I posted something that would have been ridiculous to even think about 726 days ago.

Utah, Nebraska and Idaho all voted to expand Medicaid last night.

Funding Expansion via a tobacco tax in Montana is failing. The Montana legislature and governor will now need to figure out what they want to do next.

The next round of Medicaid Expansion stories is in the governors races in Kansas and Maine.

Five states can plausibly expand Medicaid at some point in mid-2019 or on January 1, 2020. Another state, Virginia, is currently enrolling people into Medicaid with a go-live date of January 1, 2019. The deals for subsidized individuals on the Exchange are, in some counties, ridiculously good (there is an op-ed I really need to write and shop around about this!)

I went silent for a week for my own health and to actually process and think. I’m glad I did that.  I had two reaction posts the week after the 2016 election.


We’re going to lose a lot.

Let’s acknowledge that and then let’s figure out how to fight to prevent the losses that are preventable and get back into a position where we have at least one veto point if not the entire shebang.

This week, we got divided government again. It is not the whole shebang, but it is a veto point that is not reliant on marginal Republicans doing “not Republican” things.


  • the poor-shaming Medicaid waivers that tie Medicaid to work requirements will go through in thirty three seconds or less….
  • Cost control is out the door. So insurers and more notably, providers will be snorting the finest coke off the tight asses of the best hookers again.
  • Any Republican plan will include throwing more tax advantages at HSA’s (which are great for people who are truly insuring against hit by the meteor events AND have money) and telling everyone else to pay more for their own care

At least two of those things are true.

Work requirement waivers are slowly working their way through the courts and are being implemented and achieving their actual objectives of reducing enrollment in Arkansas. HSAs are continually promoted to solve any and all problems. Insurers and providers are profitable. I expect ACA insurers in 2018 to be Scrooge McDucking it at year-end. I am happily surprised and supportive of the efforts by CMS to eliminate some of the more perverse billing and organizational incentives.

We got here because we got to choose how to fight and probably lose in that fight which we happened to win. In May 2017, I wrote:

We aren’t going to win often but we get to choose how to lose. We can roll over without trying to defend our values and our morals or we can fight as hard as we can to either get a policy win or inflict significant political costs on Republicans to increase the probability of future policy wins by either putting the fear of losing their seats into them which constrains future opportunity space or flipping those seats in 2018.

More subtly, we tell stories to ourselves. I want those stories that I tell to myself about me to be true. Defending and improving the ACA is one of those stories that I tell myself. The ACA benefits 2009 me far more than it benefits the 2017 me. It is a gut check. Am I full of shit or do I actually believe in what I think I believe in.

In comments, TenguPhule asked:

Is this the modern version of come back with your shield or on it?

It was.

And we came back with our shields.

Representative MacArthur (R-NJ-03) was defeated last night as provisional ballots were counted.  He authored the work-around that barely got the AHCA out of the House last May.  After January 3rd, the ACA’s fundamental structure and ,more importantly, funding streams including Medicaid Expansion will be untouchable without Nancy Pelosi’s permission.

Far more importantly, some of the winning Republicans were running on their supposed support of covering pre-exisiting conditions.  The truth values of those statements are highly variable but the fact that Republicans who won needed to make these statements means the default assumption of the social contract is changing.  Preexisting conditions are now part of the social contract.  And this will be even more true in 2020 when there are another two years of embedding, another two years of people getting bad news from the doctor and they worry about many things but not reclassification risk, another two years of the default status quo becoming stronger and another two years of Millennials aging into their priming voting years.

Yes, there will be administrative actions.  The new proposed rules of requiring separate bills and envelopes for abortion coverage will decrease total coverage and specific abortion coverage riders.  That is important but it is chipping at the edges instead of taking a sledgehammer to the framework.

And if you told me 726 days ago that the arguments would be on administrative rule-making within the framework of the ACA, I would have thought that the time traveller went into the wrong time stream.



28 replies
  1. 1
    maryQ says:

    So I guess the way to get states to expand medicaid is to not have a black president?

  2. 2
    Jim, Foolish Literalist says:

    I just heard the governor of Idaho on NPR, back to back clips from 2010– (paraphrase) we cannot saddle our children and our children’s children with what THOMAS JEFFERSON called the moral failure of public debt!– to yesterday: “this is an Idaho-grown solution”. Like a potato.’

    John Kasich was on MSNBC the other preening about his non-partisan, above-it-all decision to expand Medicaid, IOW expand Obamacare in Ohio. Then he blabbered about how Democrats and Republicans have no ideas. No pushback from a panel that included straight-up journalists and at least one liberal pundit (Gene Robinson).

  3. 3
    Kay says:

    I’m bitter and feeling (justifiably!) sorry for myself, obviously, but Ohio expanded Medicaid, it’s wildly popular, they will never, ever be able to take it away now and they STILL fucking vote for people who did their damndest to keep it away from the recipients.

    People like liberal policy. Unfortunately they can like liberal policy and still vote for Republicans. In a way we shoot ourselves in the foot because we work so hard to get this stuff, they like it, and then it’s popular enough that they know they can also elect crazed racists and insane people and still keep it. How long have we been protecting Social Security on behalf of recipients who wouldn’t vote for a Democrat if you paid them? A LONG time.

    You get tired of it. I don’t give a shit if they get health care anymore. If they want to choose racist folk heroes over health care for their children they should do that. It’s not my job to protect the liberal programs they rely on but then won’t vote for our people.

  4. 4


    So I guess the way to get states to expand medicaid is to not have a black president?

    No. The way to get states to expand medicaid is to make expanding medicaid the issue in those states. When people are asked directly about expanding medicaid, it turns out to be broadly popular. So elections where it’s on the ballot directly as an initiative have done really well, even in nominally conservative areas. But when they’re asked to vote for state legislatures, where the issue of medicaid expansion is wrapped up with a ton of other governance issues, it doesn’t dominate the conversation to the point that it can get a whole slate of medicaid expansion candidates elected.

  5. 5
    oldster says:

    Thank you, David.

    You fought, and we fought, and you helped us to fight, and I hope that we helped you to fight some days, too.

    I like Dems who never stop fighting.

    As the director of my gospel choir said after the Russian installation of 2016, “this is bad, but we made it through slavery, and we’re going to make it through this.” So we keep marching, and voting, and donating.

  6. 6
    Elizabelle says:

    @Kay: All the best, Kay. Was wondering how you were doing.

    Disappointed that Richard Cordray was not elected. He is, and was the best choice. Alas, Ohio.

  7. 7
    Jim, Foolish Literalist says:

    @Kay: In a way we shoot ourselves in the foot because we work so hard to get this stuff, they like it, and then it’s popular enough that they know they can also elect crazed racists and insane people and still keep it. How long have we been protecting Social Security on behalf of recipients who wouldn’t vote for a Democrat if you paid them? A LONG time.

    It isn’t often I quote Tweety Matthews, but I’ve often heard him say, “If you want to live like a Republican, vote like a Democrat.”

  8. 8
    Kay says:


    I’m ready to see some old fashioned moral hazard operate in this state. They want to freak out over a blatantly invented “caravan crisis” instead of paying attention to whether they can go to the doctor or not, maybe there’s a price for that indulgence.

    I hope they enjoyed the 2 week hate-fest on brown people. It should come with a cost. If you’re going to go on a racist bender there are consequences. I’m not on Medicaid. I don’t know why I would spend 80 volunteer hours “protecting” it for people who absolutely loathe the President who made it available because he’s not the same color as them. There’s a price adults have to pay for behavior like that. It’s time they started paying it.

  9. 9
    jonas says:

    Question for Dave: what impact will these “work requirement” policies have on people trying to access Medicaid? From what I understand, most Medicaid recipients not also on SSDI — and thus exempt from these new rules — already work at least part time. The number of people who aren’t on SSDI and also unemployed and *not* looking for work has to be vanishingly small. So is this just a bureaucratic hoop that states hope allows them throw people off the rolls when they don’t fill out a form right or something? Won’t the bureaucracy needed to actually keep track of this cost a lot more than would ever be saved in withholding benefits from, like, five people? (kind of like with the drug testing requirement)

  10. 10
    burnspbesq says:


    Not with you on this one. If giving a minority of ungrateful assholes access to affordable healthcare is the price we have to pay for much-closer-to-universal access to affordable healthcare, I’m willing to pay it.

  11. 11
    Kay says:

    @Jim, Foolish Literalist:

    “Please allow me to persuade you to elect people who keep the programs you’re wholly reliant on in place”

    Hey, who am I to say they can’t prioritize the thrill of hating and fearing “the caravan” over health care? Life is full of choices. They chose that. Until they lose something as a result of those choices they aren’t ever going to change. I myself have health insurance. If I didn’t I sure wouldn’t be spending a lot of time worrying about 1000 brown people seeking refuge. I wasn’t afraid of those adorable little girls trudging along. In fact, I would prefer to give them health insurance. They’re a better investment. They’re tough and focused, obviously.

  12. 12
    Elizabelle says:

    @Kay: I agree. The no voters should definitely face the consequences. They often do not, because Democrats want to limit the collateral damage.

    Meanwhile, back to last night’s mass shooting in Thousand Oaks, CA: In roundup story by the LA TImes:

    At nearby Los Robles Regional Medical Center, friends and family frantically searched for loved ones they hoped were not among the victims. Adam Housley, who until six weeks ago was a national correspondent for Fox News, arrived at the hospital around 3:30 a.m. searching for his niece. A guard didn’t let him through, saying the facility was on lockdown.

    He said his niece, 18-year-old Pepperdine freshman Alaina Housley, had been at the bar with several friends. Her Apple Watch and iPhone still showed her location as being on the dance floor, he said.

    “My gut is saying she’s inside the bar, dead,” he said. “I’m hoping I’m wrong.”

    Housley said he comes from a small, tightknit family. But he’s been on the scene during mass shootings before as a reporter.
    “You just don’t think that — same stupid quote — you just don’t think it’s going to happen to you,” he said.

    I guess it’s possible the niece is not in the venue, maybe at a hospital unidentified.

    And why would anyone think “it is not going to happen to you”? Each of these shootings, you could also ask “why did that not happen in my community, to my loved ones?”

    And the answer is: fate. And too many guns. It is the guns. It is not the PTSD. It is that this individual, who was reportedly known as a problem in his neighborhood, and possibly kicking in walls at his 77-year old mother’s home, bought a gun.

  13. 13
    Kay says:

    FL Update, 11/8 9:30 am:
    Ag Comm: GOP +4,109 (+.06%)
    Senate: GOP +21,899 (+.26%)
    Governor: GOP +42,948 (+.52%)
    Broward probably has 15-20k mail ballots left to count, plus unknown provisionals statewide
    Margin for machine recount: .5%
    Margin for hand recount: .25%

    That’s amazing. Usually people say “they conceded too soon” and they’re wrong but, wow, that is REALLY close.

  14. 14
    Yarrow says:

    @Kay: Any chance the new OH Gov will take away the Medicaid expansion? Didn’t that happen in Kentucky?

  15. 15

    @jonas: Work requirements are fundamentally paperwork requirements with a lot of middle class privilege and stability assumptions intermixed especially for folks who earn too much to qualify for legacy Medicaid and not enough to qualify for ACA subsidies as they are already working (some/a lot) but don’t make enough money. It will depress enrollment and increase PMPM costs for no employment incentive effect.

  16. 16

    @Yarrow: Medicaid expansion is ongoing in Kentucky; just intentionally harder to access.

  17. 17
    rikyrah says:


    Morning Kay.

    I feel you.

  18. 18
    cain says:


    You get tired of it. I don’t give a shit if they get health care anymore. If they want to choose racist folk heroes over health care for their children they should do that. It’s not my job to protect the liberal programs they rely on but then won’t vote for our people.

    I feel similar and I’ve always felt that we should just start a co-op program for like minded people and create our own HMO or something and just protect ourselves. If they don’t want healthcare, then fine.. let’s set up something for ourselves who do care.
    Of course, if successful, you know both companies and conservatives will want to co-opt it and conservative voters will whine. But fuck em. We’re going to be like Noah, and build the fucking Ark and let the conservatives get swept away.

  19. 19
    Kay says:


    I just don’t get that mindset either. I don’t think I ever in my life have thought “that can’t happen to me”. I don’t know if it’s just temperament or whatever but I have never in my life felt as secure as these people apparently do. A shooting in this town would the least surprising thing ever. Half of them are armed to the teeth and fully 10% of that half are nuts.

  20. 20
    Elizabelle says:

    @Kay: I know. I am a “there but for the grace of [fate]” type myself.

  21. 21
    Kay says:


    I had this disconnect after September 11th. People were saying they felt invulnerable up to that event. Really? I’m amazed complex systems work at all most of the time. Our defenses failed? That certainly seems within the realm of possibility.

  22. 22
    Barbara says:

    @oldster: I second this comment. I was shell shocked like a lot of people and assumed that the ACA would be gone, or would be so warped that people would say that it had failed as a result of its own weaknesses. I really credit David for coming in here and providing quick analysis of each and every proposal and motivating me, at least, to use my Facebook account to inform and motivate others.

    Regarding the expansion population voting against their own interests — I don’t know whether, on average, this is true. I think we’ve seen a lot of studies that show that low income people who do vote are far more likely to vote for Democratic candidates. However, they are less likely to vote. Reliable Republican voters by and large are not relying on Medicaid — increasingly, they are relying on Medicare (which they insist they “earned” even though continued funding depends almost entirely on taxes paid by current workers) or are highly paid enough to be in the private insurance market, and most likely have employer provided insurance. Let’s not target poor people based on an assumption that they voted against their own interests. I know this can be true, but I don’t think it is necessarily the norm.

  23. 23

    @Barbara: first, thank you for the first paragraph

    Second — I wish I wrote your second paragraph.

  24. 24
    Sab says:

    @Kay: I really think Kasich expanding medicaid saved the GOP in Ohio this time. It allows them to pretend they are moderates. Mike deWine ran on positions 180 degrees different from what he has done in office over the last seven years and he got away with it.

  25. 25
    biff murphy says:

    Funding Expansion via a tobacco tax in Montana is failing…legalize the pot and have it pay for health care. Voila

  26. 26
    cursorial says:

    (Somewhat tangential to ACA, sorry; but your “we’re going to lose a lot” phrase crystallized something for me)

    I think we should embrace the “We’re going to lose a lot” expectation in another sense, and find a way to celebrate it. Because while I was discouraged by how some high-profile races turned out Tuesday, when I had a chance to process it, what it really confirmed is that we’re doing much, much better at contesting every election. Running against powerful GOP incumbents and in deep red territory means losing. A lot. Most long shots, by definition, fail. As do half of toss-ups.

    We could have flipped the House by just targeting the likely races. And if we had, we would have “looked” more successful. The media narrative is that Democrats failed in Texas, and likely Georgia. But that’s stupid. If Dems fail in those places, it’s because we didn’t concede them from the start this time. Losing a lot is what expanding the map looks like. And I have to force myself to remember that every time I listen to pundits dissect political tactics in those races

  27. 27
    MomSense says:

    Just wanted to say thank you for all the guidance and information you serve here. You have helped so many of us.

  28. 28
    Barbara says:

    @cursorial: A very late comment to say amen. This is so, so true.

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