As Mitt Romney and President Barack Obama pack in some last-minute campaigning before Tuesday’s election, polls show voters are split just about down the middle on who they prefer: Romney, who has promised to do everything he can do repeal the 2010 health reform law, and Obama, who says its benefits are just beginning to take hold.
But while the presidential race gets most of the attention, the choices voters make to fill governor’s mansions and state legislatures may have just as big an effect on what kind of health coverage they will have in coming years.
That’s in part because the Affordable Care Act sets it up that way, but even more so because the Supreme Court says it’s up to states to decide whether and how to expand the Medicaid health insurance plan for the poor.
“One thing the voters should be aware of is what are their governors are going to be doing. Will more people have access to Medicaid or access to a state-run exchange?” says John Poelman of healthcare consulting firm Leavitt Partners and a former health policy analyst at the Department of Health and Human Services.
Two states at the two extremes of health care coverage are Texas, with a free-market, bare-bones approach, and Vermont, which is unabashedly going for a European-style, government-supported system.
Brandi DeFrank is one of the 6.3 million people in Texas who lack health insurance. That's a quarter of the state's population and the highest percentage of uninsured people in the country.
Like millions of women across the country, DeFrank, 20, was fully covered under Medicaid, the state-federal health insurance plan for low-income people, while she was pregnant. The birth of her 3-month-old son, Gabriel, was also covered, but after that, her own coverage ended. The baby remains on Medicaid -- all states make some provision for children whose parents lack insurance -- but now DeFrank is on her own and gambling that she won’t get sick.
Under federal law, DeFrank could have been covered under her parents’ health insurance. But when she moved out at 18, her father said she had to learn to be an adult.
“He took me off his insurance,” said DeFrank as she cradled Gabriel in a cheerful playroom at Legacy Community Health Services, a non-profit health clinic in southwest Houston where Gabriel gets care. Her husband, who is working as an intern at a medical clinic, is also not covered, says DeFrank, who is about to begin applying to nursing school.
“I didn’t really think about Medicaid or anything. You’re just thinking about college,” she added. “I saved all my money for books.”
'We're not going to be a part of socializing health care'
Texas governor Rick Perry, a Republican, has said he won’t expand Medicaid to cover people like DeFrank, and the Republican-dominated Texas legislature backed him in turning down $76 billion in federal matching funds that would have helped pay to do it over the first five years.
“We’re just not going to be a part of … socializing health care in the state of Texas,” Perry told reporters in July.
But in Vermont, Gov. Peter Shumlin, a Democrat, and the current legislature are pushing hard for a single-payer system that they say will give them the leverage to lower prices and provide better care for everyone in the state. But they’re not there yet and the election will decide if the state will continue to go in that direction, or whether it will be forced to roll back.
The state’s current continuum of programs asks patients to pay at least a minimum premium if they can. They include Catamount Health, a state plan providing subsidies for some people, along with Blue Cross Blue Shield of Vermont; Vermont Health Access Plan, which provides insurance for people who have gone without for a year or more; Dr. Dynasaur; Medicaid, and pharmacy assistance and premium assistance programs.
On Tuesday, residents will go to the polls to decide whether to keep pushing more, towards government-directed health care plan that covers everyone, paid for by taxes.
That’s what Anna Gebhardt would like to see happen. Even though Vermont offers more coverage options for low-income families than some other states, she and her husband, Oliver, don’t have insurance. Their jobs don’t offer coverage, they can’t afford to buy a private policy and, since Oliver got a raise a few months ago at his job as an audio engineer, they earn too much money to qualify for Medicaid. Their children, Leviah, 6, and Immanuel, 13, are covered under the state’s Dr. Dynasaur program, which offers low-cost coverage for kids, but the family struggles to make the payments for it.
Two weeks ago, Gebhardt, a 33-year-old preschool teacher, was sitting nervously in a Burlington, Vt., emergency room after Leviah fell down at school. When the girl was still crying hours later, her mother took her in. It wasn’t an easy decision. Gebhardt was not entirely sure she was paid up on Anna’s health insurance premium under the Dr. Dynasaur program.
“My fingers were crossed and I was thinking ‘Did I pay the bill last month?’” said Gebhardt. “Two other people had to come over and help make sure we were covered before we could even see a doctor. This gives you a lot of anxiety when you have a child who is crying and in pain,” Gebhardt said. Luckily, she had paid and Leviah was just just fine.
DeFrank and Gebhardt are just the type of people that Democrats want to reach with expanded health care, subsidized by the government if needed. And they’re just the type of people that Republicans say could buy their own insurance if the government would just let the free market take over.
The 2010 Affordable Care Act was designed to transform health care in the United States, which most experts agree currently costs too much and leaves far too many people without health insurance. The Affordable Care Act calls for states to set up insurance exchanges, where people who don’t have health insurance through an employer or through government programs can go and buy a plan -- with government subsidies, if they need them.
It also was meant to provide more care to people who can’t buy insurance by forcing states to expand Medicaid. The hope was to add about 16 million of the poorest people to the rolls -- about half of those who need health insurance. But after a series of challenges to the law, the U.S. Supreme Court ruled in June that the Medicaid expansion requirement went too far. While most of the Affordable Care Act was constitutional, the court ruled, the federal government could not force states to offer Medicaid to more people.
'They can disrupt implementation of the law'
So now two of the biggest provisions of the law -- offering Medicaid to more people and setting up the health exchanges -- are in the hands of state officials.
“They can disrupt implementation of the law. Leadership can either be aggressively moving it forward or impeding it,” Poelman says.
The Obama administration is offering to pay the full cost of expanding Medicaid at first, but lawmakers in states like Texas say they can barely afford Medicaid now, let alone when they’ll have to start kicking in 7 percent for all those extra people in 2019.
This frustrates Garnet Coleman, a Democrat in the Texas legislature who represents much of Houston’s poor downtown. Coleman says not only would expanding Medicaid save money in the long run, by getting people treated earlier, it would create much-needed jobs. “Health care is a growth sector,” Coleman says. It will create “beaucoup jobs -- good jobs, as your mama would say.” Jobs that people can get with two-year degrees. “This is just a boost in the arm to the state of Texas,” he says.
Coleman is delighted that Perry and the legislature are balking on setting up an exchange for Texas and looks forward to seeing what the federal government will do instead. The 2010 health reform law says that if states don’t set up their own exchanges by 2014, HHS will do it for them.
Different paths to the same goal
It’s not that Democrats want health care and Republicans don’t. Both sides agree in principle that it’s better for everyone to have health insurance of some kind. It’s cheaper to treat disease or injuries early, and best to prevent disease in the first place. People are more likely to get vaccinated and to take medications such as blood pressure drugs if they’re seeing a doctor regularly.
The Obama administration says the way to get there is with subsidies and government oversight, with a healthy marketplace allowing private health insurers to offer more to those who can pay -- and strict regulation to make sure insurance companies don’t cherry-pick the healthiest customers or dump patients just when they need insurance the most.
Republicans argue that freeing up the marketplace would do that more efficiently. They say that government regulations make it impossible for insurers and health care providers to compete enough to bring costs down.
“No one says it’s better to leave people out,” says Joel Ario, former director of health insurance exchanges at HHS, who is now at law and consulting firm Manatt Phelps & Phillips. “It is just a question of what we can afford or not afford.” It’s also a question of who can best make those decisions – states or the federal government.
“With exchanges, the question is whether the federal government should have a heavy hand in making them work,” Ario added.
In Texas, polls suggest the Republicans will dominate. This likely means Texas will continue to offer a bare minimum of health care and will let the federal government set up its health exchanges.
“There are states referred to as ‘Hell, no states’,” said David Smith, an analyst at Leavitt, the healthcare consulting firm. “A lot of those states don’t necessarily have governors who are up for election.” In those states, voters have to decide whether to help governors by electing members of the same party to the state house.
In Vermont, Shumlin’s Republican opponent, Randy Brock, says single-payer health care is too expensive. Vermont’s legislature will take up the question of how to pay for it in January, with options including a capital gains tax or a tax on employers.
Where other states stand
Republican governors like Iowa’s Terry Branstad, Arizona's Jan Brewer, Sam Brownback of Kansas, Louisiana’s Bobby Jindal, Nebraska’s Dave Heineman, Nikki Haley of South Carolina and Scott Walker of Wisconsin say they have no intention of expanding Medicaid. Florida’s Rick Scott says he won’t expand Medicaid even though his state has the second-highest rate of uninsured adults, after Texas.
Leavitt’s team predicts the majority of state governors -- at least 30 -- will be Republican after the election. Eleven states will be electing governors, and eight of them have Democrats in office now.
States that are safe for Democrats include Maryland, where Gov. Martin O'Malley was one of the first governors to move on health reform. Oregon governor John Kitzhaber also makes health reform a central policy.
Next door in Washington state, health care is playing a big role in making the race tight, with Democrat Jay Inslee, an eight-term congressman from Seattle, battling the Republican state attorney general Rob McKenna. Inslee supported the health law in Congress; McKenna isn’t against expansion but he thinks Medicaid patients should share some of the costs.
In Indiana’s race, Republican congressman Mike Pence has said he wouldn’t set up a state insurance exchange. His Democratic opponent John Gregg hasn’t endorsed the health reform law, either, but has met with current governor Mitch Daniels about how Indiana should move forward on building a health insurance exchange.
Alabama, Florida, Montana and Wyoming have ballot measures asking residents whether they want to block the mandate requiring people to get health insurance. Missouri voters are being asked to decide whether to allow the governor to establish health insurance exchanges.
While they wait to see what happens, Gebhardt and her husband, Oliver, are gambling that they won’t get sick and need medical care.
“We are constantly at the whim of decisions being made by people who don’t depend on those services and don’t realize how their decisions affect people,” Gebhardt said. “We are constantly in limbo. We could create a system where efficiency works for the people and for the budget. That is where Vermont can lead the way.”