Health Care and the Governors - Why 2014 Matters more than 2012

How Voter Fraud, the Affordable Care Act, and Republican Governors fit together in 2014

For more wild speculation, read on;

The Health Care Reform movement is all about taking gubernatorial primacy. The big fail for the ACA is that the Medicaid expansion can't go forward as the Democrats would have liked. Basically, funding for Medicaid would have been premised on adoption of the Medicaid expansion, vis a vis the ACA by the states. If the state chose to adopt the Medicaid expansion of the ACA, then they get to keep their existing Medicaid funding; if they do not, they lose their existing Medicaid funds.

This was seen as problematic by SCOTUS. The court told the federal government that they couldn't remove the existing funds for not adopting Medicaid expansion. So it boils down to states. Here's an interesting mashup of two maps: the states that sued over the ACA, the states with 2014 Gubernatorial elections.

Blue have dems in office, red has GOP in office

So this map is an overlay of 2014 Gubernatorial elections and who sued over Obamacare. ACA proponents (in particular, the House Progressive Caucus) will have two years from yesterday, where Obama actually started selling this legislation, to convince the states and citizens that they want at least one feature of the ACA.

On the steps of the supreme court, Dems spoke tersely and with a certain discipline typically lacking when they coordinate; each one brought up one compelling use case for a feature. Three female Senators got up and spoke about the lady tax being abolished. It's hard to speak against regulating into oblivion the practice of charging women 30% more in premiums due to the fact that they get pregnant (or they don't, and need family planning aids), have lady tests (as if guys didn't have guy tests), and they are on an actuarial level likely enough to get domestically abused that they might need ER care for that. And they live longer. Leeches.

Anyway, there will be a fight for the middle on any given day in American politics. I can't say that they meant to do it, but opponents of the ACA have a problem with it as a service. As a tax, or as spending, or as something that doesn't impact Americans and only impacts some imaginary national debt, the GOP have framed a successful fight. As a service, as a set of provisions and regulations to restructure health care by way of insurance practices, the GOP have been cowing to the stand-by tactic of FUD (fear, uncertainty, doubt) and speculation on how the industry will reshape itself. This has been a successful lens insofar as the provisions have just begun to reach the electorate. People are only beginning to understand how the ACA will impact them, for better and for worse.

Once the 2014 gubernatorial elections roll around, however, there will have been two years of implementation and selling. Granted, this is premised on the assumption that Obama wins or Romney/Congressional GOP are unable to repeal the law. Whether by strategy or by luck or by eletoral genotypes, this will make the 2014 elections utterly amazing. Each gubernatorial candidate will be either for Medicaid expansion, or against it.

 That sounds simple. But it's not. It's a huge blind, an enormous gambit. It amounts to the most ambitious attack on the GOP by Democrats, and I don't think they even engineered it. Basically, if the Democrat talking point and refrain is "To be on the wrong side of the ACA is to be on the wrong side of history", then the analysis that Health Care Reform is the Republican's Waterloo may actually not be baseless grandstanding.

The Gambit

Follow me through a viable future reality:

• [2011-2015 ACA Implementation Timeline]

• November 2012 - Obama wins re-election after selling the ACA, touting the death of Bin Laden while effectively distracting from drones, and attacking the Romney model of economics at a personal level and getting people to finally admit that shit could have been a lot worse and we somehow bloodily limped along reasonably well considering how utterly fucked we should have been. (Again, I'm not predicting this will happen, just saying it's possible)
• Highlights of the ACA Implementation timeline for 2013:

Improving Quality and Lowering Costs 

• Improving Preventive Health Coverage.  
• Expanded Authority to Bundle Payments. 

Increasing Access to Affordable Care 

• Increasing Medicaid Payments for Primary Care Doctors.  As Medicaid programs and providers prepare to cover more patients in 2014, the Act requires states to pay primary care physicians no less than 100 percent of Medicare payment rates in 2013 and 2014 for primary care services. The increase is fully funded by the federal government.Effective January 1, 2013. 
• Additional Funding for the Children's Health Insurance Program.  

• June 2013 - Under their "ACA Voter Mandate" (you can be sure we'll hear that if Obama gets re-elected it's because of health care)Congressional dems push through a provision that revises dispursement rules for Medicaid, wherein a federal minimum is established, which states that abstain from Medicare expansion will receive and a federal maximum is established, which states that adopt will receive in addition the to Medicaid expansion "gift"
• Highlights of the ACA Implementation timeline for 2014:

New Consumer Protections 

• No Discrimination Due to Pre-Existing Conditions or Gender. 
• Ensuring Free Choice.  Workers who cannot afford the coverage provided by their employer may take whatever funds their employer might have contributed to their insurance and use these resources to help purchase a more affordable plan in the new health insurance exchanges.  
• Eliminating Annual Limits on Insurance Coverage.  The law prohibits plans from imposing annual dollar limits on the amount of coverage. 
• Ensuring Coverage for Individuals Participating in Clinical Trials. 

Improving Quality and Lowering Costs 

• Makes Care More Affordable.  The act includes tax credits to make it easier for the middle class to afford insurance will become available for people with incomes above 100 percent and below 400 percent of poverty ($43,000 for an individual or $88,000 for a family of four in 2010) who are not eligible for or offered other affordable coverage.  These individuals may also qualify for reduced cost-sharing (e.g. copayments, coinsurance, and deductibles).  
• Establishing Health Insurance Exchanges.  
• Small Business Tax Credit.  The law implements the second phase of the small business tax credit for qualified small businesses and small non-profit organizations. In this phase, the credit is up to 50 percent of the employer's contribution to provide health insurance for employees.  There is also up to a 35 percent credit for small nonprofit organizations.  

Increasing Access to Affordable Care 

• Increasing Access to Medicaid.  Americans who earn less than 133 percent of poverty (approximately $14,000 for an individual and $29,000 for a family of four) will be eligible to enroll in Medicaid. States will receive 100 percent federal funding for the first three years to support this expanded coverage, phasing to 90 percent federal funding in subsequent years. Effective January 1, 2014. 
• Promoting Individual Responsibility. (<- this is the first time people might get nicked for money from the government, but it won't happen until 2015 , and the first suit wouldn't get heard until 2016, and since the "penalty" is basically optional and can't be compelled by the government, it would be likely dismissed on the grounds that the plaintiff had no grounds to sue)

Governors will be facing down a challenging election, and a difficult two years prior. They must needs choose for or against accepting the Medicaid expansion. Today, yesterday, yesteryear, this was an easy position to stake out without much fear of reprimand. The Tea wing of the Republican party was able to censure some supporters, particularly vulnerable Republicans, but otherwise, the electorate was too unaware  in 2010 to have an opinion to bring into the voting booth in any meaningful way.

2014

2014 will not be the same:

Dems will have two years to sell the service and rights afforded the electorate under the ACA. Old people will have been given something they damn well hope they can count on and you better not fuck with it. Medicaid patients and the newly insured will be entering the rolls, and people will feel the burden of insurance lessen substantively. Hospitals and Doctors will adopt regulatory practices of bundling and streamlining paperwork (benefitting their administrative costs and patients), will receive more money for treating Medicaid patients, and a broadening of the client base. Insurance companies too will adopt bundling procedures, and have a federal guarantee on debts. They will be able to bill hospitals uniformly, and hospitals will receive payments more uniformly. (Highly dubious that it would be perfect, but I'm sure that it will improve since everybody gets to make more money if it does.) Under-regulated insurance exchanges will have opened, likely creating a lucrative play thing for deft financiers and agile insurance companies.

Gubernatorial candidates will be able to (1) champion small government, and stand behind not adopting the Affordable Care Act, or they will be able to (2) champion insuring every one of their constituents, with at least 90% of the cost paid for Medicaid patients by the federal government. Ohio's Governor Kasich, for instance, will be an incumbent (though he said he would limit himself to one term only) Republican Governor, who has sworn off the ACA as bad law. Using old numbers, the Catholic Conference of Ohio published a pamphlet in 2011 (advocating for health care form) that cited 1.3 million uninsured in Ohio, 16% of adults 19-64, and 149,000 of whom are children (source was 2008 OHFS numbers).

Now I wouldn't dare to make any guesses about whether Kasich will even want to run again, but whether it's him or another Republican going after a largely Red swing state, staking a claim around Health Care and Medicaid expansion will be interesting. Taking Kasich for example, he doesn't like ACA, it imposes a few hundred millions of dollars of increased liabilities on a state that doesn't have much scratch and what scratch it got was on the blood and bones of a lot of personnel and programs.

He can legitimately say, "we, as in Ohio, can't afford it." After four years of cuts, would the electorate abide that explanation? He could cite the talking points; blah blah communism blah blah France blah Greece socialism. Running for cover there (a) isn't what Kasich himself would do, and (b) wouldn't be effective after four years of the same and two years of benefits. He can say "not now," or "we're not ready to raise taxes right now." He can say "it'lll just add to our national debt." The latter two being things uninsured people won't care about.

Who Votes

But will the underinsured and uninsured vote? Typically, disparities in voting participation break along socio-economic lines. Normally the answer, as was the case in 2010, is no. So what happened in 2008? We had an outpouring of people who came out to vote for the first black president and people who came out to vote for anyone but a republican and people who came out to vote for health care reform. If there's one buyer-beware that motivated my vote in 2008, it was health care reform. You can be damn sure that the democrats want those 2008 voters back on their side and motivated to get to a poll for 2012. But those kind of voters don't come out in non-essential elections, they don't care about midterms.

BUT HOW DOES THIS RELATE TO GUBS IN 2014??!? The GUBS will need to decide if they want to get those voters or not. Those voters are coming out in 2014. Kasich won't sign on in advance, suit was filed by Ohio against the law, but people are damn sure going to find out about the ACA if dems in the state and progressives in the media have their way. I anticipate that a lot of red to the bone red states will be in play in 2014. Each of those states that sued? Will each have the stomach to litigate this again, or deny millions of people health insurance? Can they make that case? I don't know.

Five states in the South sued to get out of the ACA; those gubs are up for election in 2014. Do you think Republican parties are confident that millions of impoverished voters won't roll out on voting day to ensure they get insured for free? And will the GOP candidate be backing that measure?

The Republican party has invested so much of its id in state politics, and wisely so. It's cheaper to control, works as a great testing ground for policies, more granular in implementing policy, and creates more human cause celebres per capita. Investing in "state's rights" was the smartest thing the 2000s taught the GOP. Now they can always have a bevy of qualified Republican Governors, with executive experience, who can run a country. (The corresponding curse being that Democrats are always legislators, and less attractive thereby as they are not persons of action.) If the Republicans end up being on the wrong side of history with health care reform, it could mean the utter divestment of stock in Republican state dominance.

So bear in mind, right or wrong, that all those voter ID and eligibility and corollary items will have one very important thread of talking points in the contrary:

• [voter ID laws discriminate, or so says exactly who you'd think]
• ["Raising the unsubstantiated specter of mass voter fraud suits a particular policy agenda"]
• [voter fraud occurs at a rate of between some thousandths or millionths of a percent].
  • These are not to be assumed as neutral voices. 

That Democrats don't come out and vote in midterms is an accepted fact, or if it isn't it should be. 2014 will change that. Can Republicans redefine the ACA sufficiently as to allow them to not come out on the perceived wrong side of history? Hell, I don't know. I'm not going to a say I've got the right answers. What I will say is that if this plausible reality materializes, some major changes are going to come down. But will it not make people more afraid? Will their fear make them better consumers of anti-ACA coding?