Don't Mourn, Organize

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.

First:

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.

Second:

• 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.

726 Days of perspectivePost + Comments (28)