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Obamacare Gets a Bright Spot in a Very Bad Week

Mark Wilson/Getty

In the spring of 2012, while reporting a piece on the political landscape in Ohio, I spent several hours on two successive afternoons tagging along with canvassers from Working America, the AFL-CIO affiliate that tries to mobilize people who don’t have a union to join at work but would like to be part of the organized labor mission. In a working class neighborhood of small bungalows in north-central Columbus, we came upon many voters such as this one:

At the next house, a slightly chaotic scene swirled around James Tichenor, a 50-year-old who works at a local McDonald’s. 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. [The canvasser] 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.

A couple months after that encounter, I thought of Tichenor again when the Supreme Court ruled that he and millions of working poor like him would not necessarily be qualifying for Medicaid: a 7-2 majority of the court ruled, while upholding the constitutionality of the Affordable Care Act, that states did not have to participate in the expansion of Medicaid. Supporters of the law were so relieved that it was being allowed to stand that the devastating impact of the Medicaid ruling was not fully acknowledged at the time—surely, many said, states would not turn down the great deal offered by the expansion, in which the federal government picks up the full cost at the outset, before tapering down to 90 percent. Well, as we now know, that was an overestimation: as it now stands, half of all states have refused to expand Medicaid, including the two with the largest numbers of uninsured residents, Texas and Florida, leaving millions of the neediest Americans uncovered by the new law.

But no longer in that group is Ohio, the seventh largest state in the country and the largest one with a Republican governor to approve the expansion (Pennsylvania, the sixth largest, is still in limbo—Gov. Tom Corbett has come around but his fellow Republicans in the legislature are still balking.) The move makes eligible for coverage James Tichenor and at least 275,000 other Ohioans under or just above the poverty level whose income was too high for Ohio’s stingy pre-ACA Medicaid standards but too low to qualify for the subsidized private plans being offered on the new insurance exchanges created by the law. To put that in context: The newly eligible population in Ohio is larger than the population of each Akron and Dayton, and nearly as large as that of Toledo, the state’s fourth largest city. It is, in the words of the vice president of the United States, a big fucking deal.

What are we to make of this development? For one, that John Kasich is forging a remarkably serpentine path in his first term as governor. Kasich, a former Class of 1994 congressman and short-lived 2000 presidential contender, arrived in office as part of the 2010 wave that brought Scott Walker to Wisconsin and Rick Scott to Florida—“I love the Tea Party!” he yelled at an election eve rally—and quickly set about establishing his conservative credentials with the rejection of federal funds for a Cleveland-Columbus-Cincinnati train line and, more notably, the passage of a law severely constraining the collective bargaining rights of cops, teachers and other public employees. But that law resulted in a massive backlash, one that (unlike its cousin in Wisconsin) actually succeeded, in a resounding referendum defeat for the new law. Kasich seemed to get the message and started tacking back to the center, most strikingly with his push for the Medicaid expansion, which he cast in far more moral terms than those used by other expansion-seeking Republican governors, who tend to frame it as mere dollars-and-cents. From a recent Wall Street Journal profile of Kasich:

"I have a chance to shape what it means to be a Republican," Mr. Kasich said in an interview wedged between a ribbon-cutting ceremony for a new factory and a rally supporting an expansion of Medicaid, the federal-state health-care program for the poor and disabled. "I have a chance to show what it means to be successful economically but also to have a compassionate side, a caring side, to help lift people up," he said....

Mr. Kasich has lost little of the brusqueness that characterized his years as the U.S. House Budget Committee chairman in the late 1990s. When a conservative Ohio lawmaker questioned his quest to expand Medicaid, Mr. Kasich cut him off with a line he has used often since then. When you die and go to heaven, Mr. Kasich said in recounting the conversation, St. Peter is "probably not going to ask you much about what you did about keeping government small. But he is going to ask you what you did for the poor."

Mr. Kasich created a stir at a closed-door conference in California hosted by the conservative Koch brothers when he told Republican donors and activists he wouldn't apologize for his Medicaid policy. "I know this is going to upset a lot of you guys, but we have to use government to reach out to people living in the shadows," Mr. Kasich said, according to one participant, who noted that Mr. Kasich's defense "sparked an audible rumbling of disapproval in the room." Asked about it, Mr. Kasich called the reaction to his remarks "unforgettable" but said: "I really shouldn't speak about it, other than to say, 'God bless people who go to those events.' "

At a packed Medicaid rally in the Ohio statehouse after the Bob Evans lunch, Mr. Kasich ripped into those who question the motivations of the poor. "As Americans, we need to beat back this notion that when somebody's poor, somehow they are lazy," he said to loud applause from a heavily Democratic crowd. It is "unbelievable," he said, "that we live in America and there are people who don't have health insurance."

Democrats in Ohio dismissed some this talk as political posturing in advance of Kasich’s 2014 reelection campaign, arguing that Kasich was not doing nearly as much as he could to actually push the Medicaid expansion through the GOP-controlled state legislature. But Kasich’s action this week suggests a measure of real sincerity on this score: deciding he could not get the votes in Columbus, Kasich did an end run around the legislature and got the state’s obscure Controlling Board to accept the $2.55 billion (yes, billion) in federal funds that the law provides for the expansion. Republican legislators are, of course, howling and threatening to sue. While Democrats would still prefer that Kasich had pushed the expansion through the legislature to make it more permanent—they suspect he did not do so in part to keep Republicans from having to take a tough vote—they are nonetheless expressing praise for the move.

But Kasich’s move also offers a timely reminder about the import of the Affordable Care Act. It’s been somewhat lost in the mix over the past few years that the animating core of the law was in the Medicaid expansion, which was to account for a full half of the newly covered people, including most of those in the most dire straits, the working poor living in states that had set adult eligibility levels for Medicaid far below the poverty line. The Medicaid aspect was overlooked for several reasons—the law’s supporters preferred to focus on the new exchanges for people further up the income ladder, whose private plans were more politically saleable than oft-stigmatized Medicaid, and once the Supreme Court made the Medicaid expansion optional, it became clear that half of the expansion was going to fall far short of expectations, at least initially, making it even less of a popular focus for the law’s backers.

Now that the exchanges are having such initial difficulty with their Web portals, though, it behooves the law’s supporters to embrace the Medicaid aspect of the law, which, with one fell swoop, just made coverage possible to more than twice as many people in Ohio as have made it through the exchange application process in the third largest state, New York, where the exchange has been working relatively well. There are other states still on the cusp—beyond Pennsylvania, the next three most likely to come into the fold are New Hampshire, Tennessee and Virginia (much hangs on whether Terry McAuliffe becomes governor there, and can overcome the vigorous efforts of the Koch Brothers.)

And the success of the Medicaid expansion in states that accept it could well end up offering an instructive counterpoint to the difficulties being experienced so far by the exchanges. Put simply, it’s much easier to expand coverage via a government-run insurance program like Medicaid or Medicare (even if the program in turn contracts with private insurance plans, as Medicaid often does) than to try to do so with people individually choosing coverage on a marketplace of private plans. This is exactly why smart and intellectually honest conservatives Ross Douthat are feeling more discomfiture than schadenfreude over the early woes of the private-sector-based exchanges. If the exchanges are struggling after a year or two (or if an under-the-radar legal challenge that suffered an initial setback today succeeds in eviscerating them), it’s going to be hard not to notice that coverage—in the states that accepted the Medicaid expansion—extended by bigger numbers via that route. And for elected officials who think that helping people get health insurance is a good thing—including the rare Republican like John Kasich—it’s going to be hard not to draw certain conclusions from that.