Unwound (08/24/23)
Bea, Artie, and Phil discuss how the Medicaid "Unwinding," which has already seen over 5 million and counting lose their social safety net health insurance, is still being treated as such an afterthought in the press, even as the Biden administration does nothing to stop it.
Transcript by Kendra Kline. (Kendra is currently accepting freelance transcript work — email her if you need transcripts!)
[ Intro music ]
Beatrice Adler-Bolton 0:32
Welcome to the Death Panel. To support the show, become a patron at patreon.com/deathpanelpod, to get access to our second weekly bonus episode. In this week's patron bonus episode, Jules and I had a really great conversation about managed care models of health care and why we need to abolish managed care. Jules also gave us an exciting sneak peek of her new book, which is coming out January from Verso, called A Short History of Trans Misogyny. So check out that episode and become a patron to hear the first tease of Jules' new book and also about abolishing managed care. And if you'd like to help us out a little bit more, share the show with your friends, post about your favorite episodes, pick up a copy of Health Communism at your local bookstore, or request it at your local library, and follow us @deathpanel_. Anyways, moving on, today I am here with my co-hosts, Artie Vierkant.
Artie Vierkant 1:24
Hello.
Beatrice Adler-Bolton 1:25
And Phil Rocco.
Phil Rocco 1:26
Hi.
Beatrice Adler-Bolton 1:27
And the three of us will be checking back in on what may turn out to be the largest concentrated loss of health insurance coverage in US history, which has been dubbed "the Medicaid unwinding." So this unwinding that we've been covering since earlier in the year is the ongoing rolling mass disenrollment of people from state social safety net health insurance programs under Medicaid. Since we last spoke about the unwinding, the number of people confirmed to be kicked off of Medicaid has risen to 5 million people, so far. And it's looking like 1/3 of those people are children based on this data from states that are reporting age breakdowns. And for reference, the last time we talked about this, it was in a patron bonus episode in June, called Fallacies of Decomposition. And then, in June, the official count was just 1.3 million people. So there's been quite an increase. A lot of states really got going starting in July. But I just want to emphasize that this is rolling, ongoing, the process is going to take 12 months. So this is really still just the beginning in many ways. And while some in the press have started to catch on that this is “the biggest reshuffling of the health insurance landscape since Obamacare,” you know, as we've been saying, for months, this is unprecedented in terms of reversing coverage gains, some state health officials have started to respond and say actually, it's really not that big of a deal, and coverage of the Medicaid unwinding, you know, like ours, is sort of overblown, fear mongering, not helpful for the public, you know, it's undermining trust, etc., whatever. And meanwhile, the Biden administration has stepped up to claim that they're doing all that they can, despite the fact that, you know, they played such a crucial role in setting this into motion and leaving it up to the states to cruelly and creatively innovate, and they haven't done much more than send strongly worded letters and hold a few meetings. And as recently as the beginning of August, the Biden administration is still patting itself on the back for having achieved what they're calling the all time low uninsured rate of 7.7% uninsurance in the United States, which, of course, is the uninsured rate from right before --
Phil Rocco 3:32
Before [laughing], right.
Beatrice Adler-Bolton 3:33
Yeah, the unwinding began.
Artie Vierkant 3:35
And literally, I mean, like that data is from the period January to March 2023, when the unwinding began April 1. So.
Phil Rocco 3:46
Yeah.
Artie Vierkant 3:46
Very, very literally, they are touting the figure of just before the unwinding began.
Phil Rocco 3:52
Right. And I think that this is -- you know, we've been puzzling, as we do so much, right, about why this -- this is a really significant event, right? This is a really significant development around the country. And it's not just like isolated states, right? There's this sort of narrative about like, oh, you know, this state, Arkansas is like particularly horrible in the way that it's doing this, but like it is -- it is across the country, in terms of how this is rolling out. And I think the thing that we puzzle about so often with many issues is like why this hasn't achieved the level of public attention or, you know, consistent kind of media coverage of this, like as a crisis. And I think that, to me, and this is something I want to like explore a little bit on the episode today is like, I think that we have to understand that -- and I know that I've said this in one form or another before -- is like I think we have to understand that not just as sort of an indictment of people just like being inattentive to what's going on, or even an index of the complexity of what's going on, I think that you have to see, one, the significance of this event, the fact that it's happening and the fact that this many people are being disenrolled, and the fact that it's not garnering a lot of attention as a function of the structure of Medicaid itself, which is a program, that is -- if you could design a program, a public program to allow public officials at multiple levels of government to avoid blame for bad outcomes, if you design one intentionally to do that, you could probably not do better than Medicaid. And I think that you see that both in the statements of like the Biden administration, saying, like, this is really a problem for the states. And at the same time, state officials saying like, no, you know, people are like scare mongering about this. Meanwhile, they're not actually giving people due notice in ways that probably violates, you know, not a lawyer here, but they probably violate the law, right? And so it's this like circular process of blame avoidance. And I think that that very fact makes it hard to report on, but really easy to conceal just how dramatic the rollbacks on coverage are going to be. And the way that people experience it is just a blanket denial of their coverage.
Beatrice Adler-Bolton 6:20
Yeah, no, absolutely. And I think what's really important to also emphasize is that, you know, the redetermination pause was implemented quite early on into COVID, right? The idea was like, if you lose your job for any reason, you can get on Medicaid, and you can stay on Medicaid, and you can't be kicked off, you know, because of these redeterminations, that under "normal" Medicaid operating procedure sort of happen on this rolling basis. And it's part of how the program of Medicaid, which is never actually really enough funding, or enough care to provide for the population that needs it, you know, it's a way to kind of manage and ration the care, as we've been talking about all along. So with that pause, right, the pandemic has continued, and folks have been able to maintain access to health care coverage that doesn't have a sort of specific contingency related to their employment, right? But we've never actually experienced the COVID pandemic in the United States during a period where Medicaid redeterminations have been turned back on. So you know, we're seeing quite predictably, a new surge of COVID, that's, in some ways, kind of coming a little sooner than some of the surges we've seen in prior years. But this is also our first surge of COVID in the context of millions of people losing their fucking health insurance all at once, you know? The past surges, the past years of the pandemic have been under a completely different health finance landscape than the one we're moving forward in, whether that's the cost of getting vaccinated, you know, we've heard from so many listeners who have had to pay like upwards of $150 for their boosters recently, you know, the kind of framework that we're working with in our understanding of organized abandonment and the pandemic is one where Medicaid wasn't doing this, right. And it was one where we had data and we had a picture. So now, as we move forward, I know a lot of folks have been focusing on sort of the lack of data, the lack of reporting and sort of how that will shift the pandemic, but I also really want to drive everyone's attention to the fact that, you know, this health finance portion, this Medicaid portion, is also a really important, unprecedented sort of framework for how folks are supposed to "use the tools," right? Without Medicaid, a lot of people are going to, yeah, maybe get plans through the ACA, maybe some people will get it through work. A lot of people are just going to remain uninsured though. We know that when people are kicked off on these redeterminations, it's difficult to get back on. If you look at the letters that the Biden administration has been sending states, you know, states have these backlogs. There is a tremendous sort of concentration of misery that is going to come directly from what might seem like a kind of hard to see very small shift in health finance in the United States, but it has these knock on effects that are kind of terrifying to consider.
Artie Vierkant 9:12
Well, and I think putting these two things in context is really important too, because in a lot of ways, the timing and the specifics of the Medicaid unwinding are really bound up in the pandemic itself. I mean, we saw at the very end of last year, in the 2023 omnibus spending bill that was passed like at the very end of the year, is when they basically, for the first time, decoupled the Medicaid unwinding date, when these redeterminations were going to begin, from the -- originally it was set to terminate at the end of the public health emergency and they separated it out, as we talked about almost right at the beginning of the year, as we talked about, seemingly in a way to sort of I think deflect blame. The priority almost seemed like, as I've said a couple of times on the show, like avoiding having the headline be you know, Biden administration sets an end date for the public health emergency imperiling the health care of millions. Instead they separated these two things as discrete events, setting the unwinding date to begin on April 1, and then separating it from the public health emergency. But of course, these things are never separated. I mean, as you're talking about, Bea, we have -- you know, this is a very bad time to have 5 million people and counting, losing health insurance, losing their Medicaid coverage, at a time when, you know, one, we have like a new variant coming through, two, we have -- we just have information now, that the promised Biden plan for the uninsured, the HHS Bridge Access Program, which has all these problems and relies on like the good will and grace of Pfizer and Moderna, basically, to provide free shots through patient assistance programs, right, we've learned just recently that that plan for the uninsured is going to be delayed by weeks, you know, if that. So that when the new -- when the latest booster rolls out, for example, like the uninsured are not really going to be able to get it without paying exorbitant costs. And so, you know, I think almost back to what Phil was raising in terms of why this doesn't -- like why this doesn't pass into sort of a priority, really appears to me to be just because this whole thing has been bound up in this returning to normal garbage, right? Because the whole thing is -- I think, to an extent, you can look at this, if you're kind of like a high minded technocratic, whatever, liberal or something and think like, well, I mean, okay, all these people are losing coverage, right? Yes, I see the headline, all these people are losing coverage. But you know, isn't that just back to normal or whatever? Isn't that just back to -- isn't that just how things were before, and it's just happening in a concentrated way now? And I mean, sure. But first of all, you know, as we've talked about, there are these huge problems with "normal." I mean, how Medicaid has worked forever has been a gigantic problem, but then, actually, in a way, seeing this concentration all happen at once should not be a signal to say, oh, yeah, whatever, we're just back to normal now. This is back to the regular state of operations. It should be a signal to show the state of normal, actually, was a crisis. The state of normal was a problem.
Phil Rocco 12:13
And I think so, yeah, to put it in context, right, in 2018, the rate of Medicaid disenrollment, of 72 million people that were on Medicaid, 21% of them were disenrolled at some point during that year. And then of those people, I think 9 million never re-enrolled in that year, like 13% of the population. And to put this in context, like if Medicaid unwinding proceeds apace, this will be there, but it will also be above that rate, you know, from prior years of churn, just because of how many people had been enrolled. And I think one thing that I think is happening, right, is that to the extent that people can dismiss this as like going back to the normal logic of the system, the one other thing that changed is that the temporary changes, the emergency changes, it did kind of illustrate the illogic or the contradictions within Medicaid, right? Like Medicaid is a program beset by contradictions, right? On the one hand, it is described, I think, especially in recent years as this, you know, really vital program for lower income working class people, like a very large number of those people, you know, one in five Americans, half of all live births covered by Medicaid, and this sort of thing, right? At the same -- so like that image of Medicaid is like this path to coverage for a growing number of people has predominated, I think especially since the passage of the ACA. At the same time, the undergirding logic of the program as a means tested program, which every year, you know, there's this really cumbersome program of like redetermining people's eligibility in which states, as a matter of routine, skirt the boundaries and like, go beyond the boundaries of the law to kick people off. And the federal government finds itself in this very difficult position, which is, do you punish them, right? Do you punish these states for kicking people off? Or do you sort of recognize that like, imposing really sharp penalties then, you know, potentially allows them to just like -- or encourages them even, to cut more people off, right? And it's this kind of illogic that's like baked into the system. So if you look at some of the states that are now some of -- on the leader board for disenrolling people, you know, it's not just like -- this narrative that it's, you know, just Republican dominated states or conservative states, with governors like Sarah Huckabee Sanders, that's not correct. I mean, yes, those are on the leaderboard, too, but you can also look at states -- I think New Mexico, to me, is really illustrative. You know, it's a state with unified Democratic government, Democratic governor, you know, has been sort of like the poster child, even attempting to expand Medicaid even more than the regular ACA, Medicaid expansion. But yet at the same time, it is one of the leading states for disenrolling people. And it's also one of the leading states for doing things that the Centers for Medicare and Medicaid Services, the federal agency that administers this program, recognizes as potentially in violation of the law, including things like just terminating people from coverage without any sort of serious attempts at notice, and due process, waiting more than 45 days to make a determination about somebody's modified adjusted gross income. All of these really, really basic things are happening in this state where if you follow the basic partisan story, that doesn't make any sense. And then you look at the history of Medicaid coverage in New Mexico, and the state has been under a consent decree since 1990, for violating federal laws on providing notice to people in languages that are not English, right? It like systematically didn't do that. Then there was, I think, another consent decree in 2018, it still wasn't really doing that. And it still isn't doing -- like, there is a history of denying people coverage invidiously on the basis of what language they primarily speak, and that's like, very, very core, going back a very long time in New Mexico. So I think that like part of the confusion that people sort of feel or face, with interpreting what's going on right now, is the fact that this program has maintained these kind of internal contradictions and the Biden administration in kind of touting its approach to the pandemic, has always just sort of elided, necessarily, because it was never pushing for anything like even federalizing Medicaid, or Medicare for all, God forbid, right. But it wasn't even proposing anything really dramatic within Medicaid, it was just saying that like, look, we've -- with the ACA, there's been Medicaid expansion, and then you've had this continuous Eligibility Provision. So a lot more people are getting Medicaid, yay, right? But all -- at the same time, going on under this, is just this bomb that is about to be dropped. And lo and behold, in the year end budget negotiations in 2022, they didn't do anything, nothing to stop it from being dropped, right, or to challenge the conventional logic of that system. And that is a bigger -- we can get into like the policy details of all of this. But that, to me, is like the bigger political problem is there are these contradictions in the program that existed since time immemorial, rather than redressing them or addressing them, we just expand, you know, incrementally sort of like expand the program, while at the same time maintaining all of the ways in which the program routinely throws people off of its coverage.
Artie Vierkant 17:53
Yeah, absolutely. And I think, you know, if you look at the projections of how many people are poised to become uninsured, or totally lose their Medicaid coverage by the end of this process, over the course of these 12-14 months, the estimates go up to like -- the Kaiser Family Foundation estimates go up to something like 24 million people. So we're just seeing the beginning of that. And if you think about that, just in terms of the scale, not only is that sort of a comparable scale to -- I mean, like just look at, for instance, like only now the ACA, Obamacare, right, only now does the ACA have about like 30-35 million people on it. The coverage gains generally, the health insurance coverage gains, or whatever, that are part of the putative Biden legacy or whatever, like the Biden/Obama legacy, right? We're literally talking about a similar scale of coverage losses here. And this is -- you know, not to be just redounding to the gotcha of saying, oh, it's hypocritical, or whatever, but if you look at, for instance, the Biden 2020 campaign proposal for health care, one of the most key facets of it was essentially like, we're going to create a public option, partially, with the goal of capturing actually the population of people in Medicaid non-expansion states where there should be more people on Medicaid, who do not qualify simply because the governor or the state legislature of that state has decided not to expand Medicaid under the ACA. So you know, just to look at the contrast between that plan -- I know that we, during the course of the campaign, were basically like, they're not going to do this. Like this is them trying to basically say, you know, like, fuck off, all you Medicare for All advocates, like we're not going to really do anything substantive on health care. And, lo and behold, where has the public option discourse been since Biden was inaugurated? Like I mean, total, you know, tumbleweeds over here. But it is, I think, relevant to look at the promised intent of expanding health care coverage versus now, in the pursuit of back to normal, or in the pursuit of just going back to business as usual, without even trying to try any sort of technocratic fixes, like improving Medicaid, or continuing to cover people now that we just have this large group of people who have experienced a generous government program, or like a more generous government program than it was in the years before this, you know, we're just gonna, like, drop all of that.
Beatrice Adler-Bolton 20:28
Yeah. Well, I'm glad you bring it up and frame it that way, Artie, because I was actually going back to some stuff from right around the beginning of the unwinding. I remember this really weird document I had bookmarked that was like a report about, you know, how it was gonna be totally okay to do this in Pennsylvania. And I went digging through my bookmarks yesterday, because I was like, I feel like there was one thing they said in this that I can't remember the phrasing, but it like described sort of the way that Medicaid is thought about and the kind of fear around keeping the expansion in place like so well. So I dug it up, and it was this report from a terrible, disgusting perspective. It comes from a think tank called the Commonwealth Foundation, not the Commonwealth Fund, but the Commonwealth Foundation.
Phil Rocco 21:14
See what you did there.
Beatrice Adler-Bolton 21:15
Yeah [laughing]. And they bill themselves as, "Helping Pennsylvania write the next chapter in America's story by transforming free market ideas into actionable public policies." So you know, like clear goals. I was rereading this report of theirs from April 10. And a lot of it was focused on sort of hammering home the point, you know, as I say, like, even with the FMAP increase, even with the increased funding that the federal government was giving Pennsylvania, Pennsylvania was, "spending too much money relative to the revenue it was taking in." And they focus a lot on what they call the "worker to Medicaid recipient ratio." As I said, it's gross. But I want to just --
Phil Rocco 21:55
Clever.
Beatrice Adler-Bolton 21:55
Yeah -- note two things. The first is how they set up the stakes, which is the quote I was thinking about it. And they make clear that the way that those sort of like pushing the buttons on the unwinding think, you know, it's an ideology that's sort of deeply committed to a zero sum, austerity mindset, as if the kind of public-private hellscape of Medicaid is like a natural evolutionary truth of how health insurance is, I don't know, like in the wild, and we've got to restore it, we got to go back to nature. So they say regarding the stakes, "Medicaid was not designed for healthy adults. Medicaid expansion and continuous enrollment have created precedents for a disturbing trend, a slow creep towards a middle class entitlement that will further shift resources from the vulnerable to the healthy."
Artie Vierkant 22:43
Hmmm.
Beatrice Adler-Bolton 22:44
[groans]
Artie Vierkant 22:44
Well, actually, I find that very interesting, because this actually gets to something that I think is -- we've talked about this a lot as this huge, I was gonna say missed opportunity. But really, you know, I don't expect the Democratic Party to have taken this opportunity -- so I suppose, like political malpractice -- which is the fact that, and sort of I alluded to earlier even, you know, we had this window, right, where we're showing, and I think this is true of a lot of other pandemic programs as well, that went out the window before the end of the public health emergency even, but we had this window where it's kind of like we've expanded certain aspects of the welfare state, you know, there's an opportunity for -- as we know, Democrats controlled, until the beginning of this year, the White House, the House of Representatives and the Senate, right, there's an opportunity to say, we're going to make these benefits more generous, we're going to make it less onerous, we're going to make it so that for instance, you don't have to be constantly doing paperwork to prove that you're poor enough to be on Medicaid, right? And I think what I find interesting about this quote that you've brought in, Bea, is that -- what do they say, like it's creeping up to a middle class entitlement?
Beatrice Adler-Bolton 23:50
Yeah, the "slow creep towards a middle class entitlement" that they say is produced by these precedents for a disturbing trend.
Artie Vierkant 23:59
Right. So I can't help but think of -- so like a really important context overall, for Medicaid unwinding, right, is just how big Medicaid grew over the course of the public health emergency, right. So, for example, because states were restricted from dropping people from the rolls, right, for more than two years, according to analysis from Kaiser Family Foundation, between February 2020 and March 2023, Medicaid enrollment grew by 23.3 million people, to a total, by the end of March before the unwinding started, of nearly 95 million people. So if you look at that against, for example, there are like 332 or so million people in the US, that's like nearly -- I mean, it's not actually one in three, but nearly one in three people, right? Like seven out of 25 people, if you want to be really pedantic about it, like seven out of 25 people were on Medicaid, almost one in three. Then if you just -- okay, bear with me, I'm just gonna do a thought experiment. We're gonna do a little back of the envelope math here, if that's okay.
Phil Rocco 25:12
Uh oh.
Beatrice Adler-Bolton 25:14
This might have been what I prepared too.
Artie Vierkant 25:16
Okay, well, sorry.
Beatrice Adler-Bolton 25:16
Knowing our lines of thinking, I'm like --
Artie Vierkant 25:18
I wouldn't be surprised if --
Beatrice Adler-Bolton 25:19
Your math is always better than mine though, so you should be the one to do it, because I can't add and subtract to save my own ass.
Artie Vierkant 25:25
I wouldn't be surprised if we all had this idea. So you know, basically, okay, so we have 95 million people were on Medicaid until the beginning of the unwinding, roughly 95 million people. According to CMS, there are some 65 million people on Medicare, right, as of -- or there were, on Medicare as of March 2023. Also, if we -- let's add in, right, the population, I know this is gonna sound like a stretch, but like, let's add in the population, 35 million people, who are currently on a plan through the ACA exchange, and I'm saying that because --
Beatrice Adler-Bolton 26:01
A lot of them have subsidies.
Artie Vierkant 26:03
You know, Obamacare is a marketplace that exclusively exists because of the government and heavy, heavy government subsidy, right, that's specifically capturing a population of people -- I mean, it's basically a government public-private partnership marketplace for people with untraditional types of work, practically.
Beatrice Adler-Bolton 26:21
And I think it's important to kind of connect it in, because even these ghouls at the Commonwealth Foundation, right, they're saying Medicaid expansion and the continuous enrollment. So they're tying it in to the ACA, too.
Artie Vierkant 26:33
Okay, also, then, just to round this out, like 9 million people are on Veterans Health Administration health care. If we add all these together, right, including the ACA plans, and I know that there is some coverage overlap in some people, but we're just doing -- remember, we're doing back of the envelope stuff here, so. But all those things - 95 million people on Medicaid, plus the people on Medicare, ACA plans, VA health insurance, that's 205 million people, right? That is 61% of the US population, were on public health insurance as of March. If we don't count the ACA plans, if you want to be really a stickler about that, it's 51%. More than half. But if we do, if we go the other way, and we not only include the ACA plans, but we toss in the uninsured population, which we know is 7.7%, because the Biden administration is very proud of that. It was 7.7% in March. That is 68.7% of people in the US roughly, as of March 2023, were either on public health insurance or uninsured. That is nearly 70% of people. And the reason I bring this up is because I find it -- again, I find it very funny, this quote that you've brought up, of like it's creeping up into a middle class entitlement, because to me, 70% of people being either on some form of public health insurance, whether it's public, private, or not, just like a public health insurance plan, or being uninsured, that to me sounds like -- what did Pete Buttigieg call his like really trash “Medicare for All Who Want It” --
Phil Rocco 28:16
Glide -- glide path?
Artie Vierkant 28:17
Right, a glide path. That sounds to me like “a glide path to Medicare for All” if I ever saw one. And the fact that -- I mean, again, this is notable, if you're like a health finance pervert or whatever, the way that we are, this is really notable because these numbers that we're talking about, even if you just are looking at like Medicare, Medicaid, VA, right, the 51% figure, that's like for the first time those figures truly competing with like the other really big percentage, which is like employer based health insurance, right? Because as of 2021, I think it was like 48% of people had employer health insurance.
Beatrice Adler-Bolton 28:56
Yeah, the number for 2022 is 155 million in employer plans.
Artie Vierkant 29:01
My point is like in this whole thought experiment, it's like, okay, so you have -- this is this giant population of people. There are so many options here, even if you're going to do the technocratic bullshit. Like you could say, okay, well, this is a great opportunity to expand it, so that the amount that the states pay for Medicaid is nothing and the federal government pays for it, or like expand the what counts as the poverty level or something, to expand it so that like more people get coverage, right? Or in the glide path scenario that I'm sort of joking about, but taking seriously, is okay, well, we have this 71% of people are on public health insurance in some form, or are uninsured. Okay, well, let's just transform these all into one of -- you know what I mean? It's just, there are so many things you could do.
Phil Rocco 29:47
That's right. And I think it's also worth highlighting, it's like the idea that this would be this -- this would not be my preferred approach to like "nationalizing" health insurance for a variety of reasons.
Artie Vierkant 30:01
No, yeah.
Phil Rocco 30:01
But I think the interesting thing is that like, even to say that to nationalize Medicaid financing would be a heavy lift, the federal government already picks up -- 72% of all Medicaid spending that happens is the federal government, right? You think about the -- I think the reason that we have the idea in our head that the states are really important to Medicaid is primarily because they like administer the program, and they do kick in money, and they can make really important programmatic decisions about what kinds of coverage to expand and eligibility things within federal parameters and so on. But like, in reality, the federal government is doing most of the heavy lifting fiscally, and in some states is doing nearly all of it, right? In states with very, very low per capita income, it's doing, you know, nearly all of the financing. So we're already there, you know, in terms of like, in principle, and in theory, there's no hard structural barrier there. It's like, we're already nearly there. We're already nearly there also in like, you know, the fact that standards of medical care are increasingly because of Medicare and Medicaid nationalizing. You have laws like EMTALA, which determine what -- the fact that hospitals have to treat people that come into the emergency room, and so on. And so like the idea that there's this big sort of barrier to doing that is really -- it's a concoction, it's a fabrication of I think just the kind of elite policy discourse, and I think that you see it a lot in some of the -- I don't know, I would say some of the discourse that tries to minimize the significance of this. I think one of the ways that you hear some state officials like try to minimize the significance of this is to say that people who are not on -- who get disenrolled from Medicaid can then enroll in Marketplace coverage, right? And then you have to ask the question, like, why then, if Marketplace coverage, which, you know, is for some people, there are like subsidies that would effectively subsidize most or all of the coverage, if that's so good, why is enrollment so low, right? Why is it, even in 2018, when you saw disenrollment for Medicaid, only a tiny fraction of people who got disenrolled then re-enrolled on exchange plans, or through employers, or some other form, right? It's because it's not really the kind of safety net or the catch basin that they think that it is, for a variety of reasons, including just administratively like having to select a new health plan, among different options. It introduces bewilderment of various kinds. So like, I think that the existence of exchange plans also kind of helps to perpetuate this idea that all of these other solutions are sort of like lying around, and we're just like not doing it. It's like, then why, why isn't that happening, right? That's the thing that I keep running into. And it's like, if states were actually adequately giving people notice of anything, then maybe you would expect to see that, but also, it might have less to do with what states are communicating, and more to do with what the sort of structure of that program is.
Beatrice Adler-Bolton 33:07
Yeah. I mean, it's so funny, like, so the second quote from that thing that I wanted to bring in, was them sort of setting up this like hysterical existential threat by saying, "Nationally, Medicaid enrollment almost hit the sober milestone of 100 million, just as continuous enrollment ended on March 31."
Phil Rocco 33:28
Oh dear.
Beatrice Adler-Bolton 33:28
Yeah, like sobering. Yeah.
Phil Rocco 33:30
Oh dear, oh dear, oh dear.
Beatrice Adler-Bolton 33:31
I mean, the thing that I was sort of focusing on, looking at those exact same things that Artie laid out and thinking about how, you know, a lot of what we've sort of seen, actually, in the pandemic, Medicaid expansion, is basically almost exactly part of the dream of these sort of democratic, liberal, mirror world, Medicare for All policies that we saw just proliferate during the 2020 election cycle. And the sort of milestone of 100 million, you know, I think, is really important to think about for two reasons. One is like that, yes, it's part of this sort of formula, where suddenly you have a population of people on some form of public insurance, vastly equaling, to overwhelming the amount of people on employer sponsored insurance, right, which sort of like hides the ubiquity and sort of undermines the idea that well, that's the largest group, so you can't possibly fucking touch that, right? Like gotta leave that alone, because everybody loves their employer sponsored insurance. Like it's too big of a sort of population to deal with, why do we have to migrate all those people over, right? It kind of undermines those arguments first.
Artie Vierkant 34:43
Definitely.
Beatrice Adler-Bolton 34:44
The other thing, though, you know, is that I think what's sort of really fascinating if you think about the like 100 million number, right, is that it's, as you're saying Artie, it's a very obvious sort of third, almost, of the country, right, and if Medicaid's supposed to be a health insurance plan that only the most poor in the United States get, that only the most needy, the most vulnerable, the deserving non-healthy people, right, that there's this idea, right, that potentially up to one third of the population is on the dole, not working, loafing, leeching from the taxpayer, right? Like the idea of the United States losing out on this -- what did they call it again, the "worker to Medicaid recipient ratio" becomes a fucking hysterical austerity nightmare, right? Like, it's a living nightmare for these motherfuckers to think, oh my god, one third of the country is sucking on the 400 teats of Medicaid or whatever the fuck, you know, this is a kind of extraction paranoia gone wild, right? The kinds of things that we talk about all the time, the ways that Medicaid is really set up to sort of extract from the poor, to punish the poor, right, but to also, you know, incentivize work. Like all of that is justified because it's said that it's necessary to make sure people work, right. And I think part of sort of the dynamic about the unwinding, and why so many people, even those purportedly invested in health care policy, people who are Medicaid analysts, people who are Medicaid administrators, you know, to them, their belief in the end of the pandemic is just as strong as these motherfuckers at the Commonwealth Foundation, who are like, rah, rah, get everyone fucking back to work and kick them the fuck off of Medicaid so that Pennsylvania won't be in a budget deficit next year, you know, whatever. Like that kind of paranoia, I think, as part of the production of the end of the pandemic is why, you know, we see a lot of sort of apathy or like shrugging, from folks who normally sort of study this stuff and look at Medicaid, and look at the importance of Medicaid, and argue for the importance of Medicaid as a net to catch folks, right. You know, I think they're unfazed because to them, in some sense, right, like the problem of the pandemic has been posed as a problem of needing to get people back to work, right? And in the imaginary, the cultural imaginary --
Artie Vierkant 37:12
Recovery, reopening, etc. Yeah.
Beatrice Adler-Bolton 37:13
Yeah. And in the cultural imaginary of the United States, what is the thing that gets the poor people to work when nothing will? It's Medicaid, right? It's getting kicked off Medicaid. It's the ways that Medicaid can force you into employment, can shift the circumstances such that you must work. And I think that that kind of -- it's like a wish fulfillment. It's like a desire thing, where people think of Medicaid and they think, well, you know, like, the people who need the care, the real vulnerable people, they'll get it, don't worry, you know. We just have to get those other people who maybe are just like, maybe they're feeling a little nervous about going into the office, maybe they don't really feel like going back to work, maybe, you know, two weeks after giving a baby is soon enough to get back to the office, even if you had like pregnancy complications, like, that's fine. You know, that's what the state of Texas is doing. But that's also what the state of California is doing, right? Like this is not uniquely occurring in just the states that always get the bad rap. This is pretty universal. We're seeing all of these procedural denials from places like DC, California, not just --
Phil Rocco 38:21
Rhode Island.
Beatrice Adler-Bolton 38:22
Rhode Island, right? Not just Texas, Arizona, you know, like Utah, yes. But also, Cali-fucking-fornia, right? Where we just had this labor decision in the California Supreme Court where they said, you know, no, you can't hold employers responsible for forcing you into working conditions that cause you to get infected with COVID, to bring it home and endanger the people you live with, or the people in your life, because that could break the economy with a fucking flood of liability litigation. It's that same paranoia about the kind of debt eugenic burden, the non-worker, and the threat the non-worker poses to like the survival, gross, you know, power of the United States.
Artie Vierkant 39:04
Well, and I just want to pause really quickly on this thing about, because both you and Phil have brought this up, about it gets dismissed, almost, I think, by some people as just oh, there must be something that's just kind of happening in red states. Like, of course, the Democratic party controlled states would be more forgiving, or something about it, or they wouldn't be kicking people off as quickly. As you both have mentioned, that's absolutely not the case. This is a complete nationwide problem we're seeing. If you look at the data from across the states about how many people are being kicked off, including for procedural reasons, which is a thing we should talk about in a second, but if you look at the data, it's like happening across the board, regardless of who's in power, where, and I think the reason that I want to pause on this for a second is just because in so many ways, I think this conversation is kind of becoming a like why, why the fuck people are not talking about this as much as it should be, or like why, for instance, like the press or at a minimum, aren't taking this with the seriousness that it deserves and needs. I mean, this is a seismic fucking event in American health finance. But I think one reason is, I'm just going to read from this -- almost like an offhand thing in a Politico piece about this. And I think that this kind of suggests one reason why at least a lot of liberals probably don't have this at top of mind, including, and especially, I think liberals who are more invested in kind of doing rah rah Biden, Bidenomics, whatever, stuff right now. So this is from, I think two or so weeks ago. They write, "Some Biden allies dismissed political concerns tied to the disenrollments, pointing to Democrats' clear advantage on health issues in the polls. Biden's expansion of Obamacare subsidies also means more people who lose Medicaid this year may be able to afford new insurance."
Beatrice Adler-Bolton 41:00
"May" be able to afford.
Artie Vierkant 41:02
"'Coverage is at an all time high and the number of people uninsured is at an all time low. And a lot of that is because of the work of Joe Biden,' said Leslie Dach, chair of the Democrat aligned group, Protect Our Care..." Again, remember that uninsured all time low is literally from right before. But anyway, the article continues, "...arguing that red state leaders will shoulder any blame tied to coverage losses. 'These numbers are being driven by governors that have shown themselves time and time again to be opposed to healthcare.'"
Phil Rocco 41:34
Okay, so look, I mean, like, I understand why [he] has to -- look, [he] has to say that, like this is [his] job to be quoted on that, right. So okay. But then it's like -- [laughter] you know, and I understand, it's like, okay, at some deeper level, I would agree, Medicaid is a blame avoidance machine, right. Whatever else it produces for people, it also allows for blame avoidance, because of the divided administrative structure of the program. But then the question is, like, do you feel lucky, punk, right? [laughter]
Beatrice Adler-Bolton 42:10
Mhm.
Phil Rocco 42:10
I mean, it really is a Dirty Harry moment, which is that like, okay, yes, you know, you could even say that the ACA moved the -- you know, moved the floor, changed the benchmark, you know, historically, but like election cycles -- and even to the extent that voters say -- even if we're just talking about that narrow aspect of it, even to the extent that voters make decisions retrospectively, they don't have a 10 year look back window. And it's like, what happened to me in this very important year, right? Well, maybe one thing that happened to me is I got disenrolled. Who happened to be -- you know, from a federal program -
Beatrice Adler-Bolton 42:54
Who is president, yeah.
Phil Rocco 42:55
Who is president, right. And the thing is, like, if the federal government is on the hook for, I don't know, 72% of Medicaid spending, and has the ability to regulate the states, it's like, you want a little bit more than just like we sent a letter that said, you may be in violation -- to the states that said, like, you might be in violation of the law. And that like by the way, if that kind of thing worked, or even like the threat of sanction worked, then, you know, you might not see things like this. Like so Tennessee is obviously, like many states, you know, engaging in these sorts of procedural terminations of people. By that, we just mean, terminating people not because they're actually ineligible for the program, but because they don't respond to a request for information in time, or they might not fill out a form correctly, or there's some other kind of procedural problem with their redetermination application. If that were the problem, you wouldn't see things like this, like back in 2016, Tennessee also got into hot water with the federal government, because it was using these eligibility redetermination packets that were so complex that they resulted in a 10% decrease in Medicaid enrollment. So what happened after that --
Beatrice Adler-Bolton 44:14
You know people went to happy hour to celebrate that at first, and then they got in fucking trouble for it.
Phil Rocco 44:19
Right. So but like between 2017 and 2018, that's -- you saw a 10% decrease in Medicaid enrollment in that state. And, you know, what happened to Tennessee, they got slapped with a federal mitigation plan, right. They had to like file a plan that said, like, here's how we're going to mitigate these problems in the future. But guess what, like this is still happening, and not just in -- Tennessee is not unique. It's happening, like if you look at the letter that is written to Tennessee, it is an almost identical letter to the one that's written to dozens of states.
Artie Vierkant 44:56
Yeah, they're all form letters.
Phil Rocco 44:58
They're all -- it's all form letters, and the language is almost universally the same. I mean, there are some states, and I'll just rattle them off -- New Mexico, Rhode Island, Florida, Arkansas and Montana, that are, you know, across the board, there are multiple problems that might put them in violation of federal law. But like most states are doing at least one of those very important things wrong. And this is the point, is like that is the setup we have created, right? That is like a basic feature of Medicaid structure. And even to the extent that we've expanded eligibility, there's never really been a challenge to that principle that you can be disenrolled because you don't meet not just the asset test, and not just because your modified adjusted gross income or your MAGI is like, you know, too high. But also because like there any number of other kind of procedural problems. That basic thing is never been challenged.
Beatrice Adler-Bolton 45:56
Yeah, no. And I think the thing that's really fascinating is if you look at some of the explanations for like, why it's worse in certain states than others, one of the things that has emerged as a theme, particularly from folks who are kind of defending this as really not that big of a deal, they're like, see, the real problem is the states with lots of procedural disenrollment, they have really bad call wait times, you know, and so, if we could just like increase some of the money that conservative states are putting into their Medicaid staffing, right, like we could fix this. Except for --
Artie Vierkant 46:31
If we only had more bureaucrats to do this process more efficiently.
Beatrice Adler-Bolton 46:34
Yeah, I mean, the problem is, if you cross reference the letters from the Biden administration to each state and the territory of DC, each one references the wait time. Now this is as of May, right. So a lot of these letters are kind of incomplete. And they actually don't have information on like how many people are being disenrolled for procedural reasons, because a lot of these states, at that point, had not even fucking started yet right? So that's not like a great reference because it doesn't -- you have to like pull up the Kaiser Family tracker and look at the latest data on the states who are leading in procedural disenrollments, and then pull up the Biden letters and sort of compare across, right, but there are so many states where the wait time is one minute, the call drop percentage is only 3%, right? And they're still clocking in at over 50% procedural disenrollment.
Phil Rocco 47:33
Yeah, that's a good point.
Beatrice Adler-Bolton 47:34
So it is not we need more staffing. It is not, oh we need better call systems. It is not that, you know, call systems alone are producing these inequities, right. This is not a staffing issue. This is not an allocation of "human resources" issue. This is the fact that these determinations are designed and intended to produce disenrollment for procedural reasons, and they are quite effectively. And we're seeing it in a concentrated way, in a way that we don't normally actually get to look at these things, because they are on a rolling basis.
Artie Vierkant 48:07
I want to pause on this for one second, because I think to an extent, Phil just earlier did spell out some of the things that, you know, procedural disenrollment could mean. But I think that this is something that gets really short handed a lot. And I want to just take like a second to make sure that we do address this because I think -- well, when I say it gets short handed a lot, what I mean is I think this is also one of the ways that it gets sort of excused away or like becomes less of a big deal, is because, you know, you see this like big bad number, right? 5 million people disenrolled from Medicaid. And then often, you know, even just like whatever, look at like New York Times reporting, anywhere, anywhere that's actually reporting on this, you'll see often just like kicked off for procedural reasons, or paperwork issues, or filled out paperwork wrong or something. And we even are using this, you know, it took us a while to have this come up in the conversation. But like, you know, we use this shorthand too, because it's like, what we're talking about is something that we've talked about frequently on the show. We more often use the term like administrative burdens, right? I just think it's worth like pausing for a second on what that means, because this, as you're saying, this is like across the board, when you look at these 5 million people who have lost their health insurance through Medicaid, literally across states, it's 75% have lost their coverage for "procedural reasons." So that's 3.5 million of the 5 million people were kicked off because of you know, "paperwork issues." And so what that means is, you know, it's important just to note, it's like that means a multitude of things, but when you just kind of -- when it gets collapsed into "for procedural reasons," I feel like it's easy to have your eyes glaze over, just be like a term that you don't pay attention to, if that makes sense. So, you know, that could mean a multitude of things. Like it could mean states resumed redeterminations and a lot of people reasonably, like very reasonably didn't know that they had to send paperwork in, for instance, because the process has been paused for two years. It could mean something that Phil mentioned earlier, that paperwork that was sent to them was not in the appropriate language. It could mean maybe the state tried to reach out to them for eligibility paperwork, and they had moved, they had a new address, or like a new phone number, so they didn't get the phone call, didn't get like -- didn't get a letter, didn't get a phone call. Maybe they -- you know, this is a universally poor population, it could be that they didn't have housing in the first place, so it's very difficult to find them.
Beatrice Adler-Bolton 50:42
Or they didn't get it back in time, because shit gets in the way, I mean.
Artie Vierkant 50:46
Exactly. But that's what -- this is what I'm getting to. There's like -- and that's just the possibilities of like, if the state is unable to contact them, right. There's also like, you know, there are all these varieties of what this could be, which all gets collapsed as "procedural reasons." And often, the actual experience of that is just going to be, for a lot of people in the scenarios that I listed just a moment ago, you're probably only even going to realize that you've lost coverage when you're going to a doctor or trying to pick up a prescription, or, you know, I'm sure this has happened, a lot of people tell -- a lot of people already, like they get a bill for a procedure or a visit that's already happened, right, and what's important to mention is when we're talking about procedural reasons, what we're talking about is like they're denied because of the structural things in Medicaid, the structural administrative burdens that are, first of all, the problem, a huge problem with Medicaid in the first place, but also a huge problem with a lot of the structures of the US welfare state, or of like state apparatuses in general, right. This is -- it's like, it reminds me of when we talk about -- like when Ruth Wilson Gilmore talks about incarceration as the extraction of time, right? I think it's like a very similar process here, like that extraction of time is what we're talking about here when we're talking about people being denied over paperwork or paperwork issues, right, or procedural reasons. It's these extreme administrative burdens that when you run out of the time and energy to be extracted from, right, to do them, leads to a denial just because like you've had all the time and energy extracted from you already, and you just become illegible to the state.
Phil Rocco 52:24
Right.
Beatrice Adler-Bolton 52:25
Well, and I mean, this is where the kind of idea that, oh, this can simply be fixed by dealing with wait times, right, or making the paperwork better, kind of falls flat, right? Like the idea being, oh, well, if the paperwork's bad, and you can get through to the call center, then you can get it worked out, right. But even those sort of moments, you know, as you're saying, Artie, they add additional time, but I think that in so many ways, you know, like it just makes me think of all the conversations we've had with you over so many years now, Phil, where it's just like, this is that kind of like health policy solutionism, right? Where it's like simply streamline the paperwork, make a better slide deck, hire more people to administer the machine, right? Not that the machine structure needs to be changed, fundamentally.
Phil Rocco 53:14
Right. Well, okay, I guess this is the way I think about it. So there's some things -- like, okay, there's some states where they are really strapped for employees, and like the fact that there aren't enough people, like that is probably contributing to some administrative problem, yes? I mean, that seems pretty basic to me. There are states that are, you know, to an extent that it's like more aggressive than others, they do want to cut people -- like they want as aggressive a policy on Medicaid as possible, because it comports with their broader approach to the political economy where they're trying to create the bridge to the 19th century, right? Obviously. You know, but the thing is, I don't think that trying to fight all of those battles individually, anybody has the kind of leverage at the state level that they really need to do it. I mean, frankly, I mean, it's like, what do you -- like, you know, you can sue, but like, I don't know, it's like, how confident are you in the Fifth Circuit Court of Appeals, right, is going to -- like come on, you know these people -- like you know who sits on these courts, okay. That's not going to work. There is, however, at least in the immediate term on policy, like CMS has the authority to stop procedural terminations. To stop them, okay. And to stop them, not just for like one state, but for a bunch of states that they have identified. And then the question is like, what is happening, right, and we don't really know. There's some indication that CMS has like worked with 14 states to change their process, but we don't even know what 14 states those are. I read that in some reporting. We haven't even identified the 14 states that like CMS has been like "working productively with." But the point is, at some point, you either have the statutory authority to do this, or you don't. And the thing is, like, if you don't use it, what the hell good, is it, right? And so that's the thing that like, I think, you know, just as a policy matter, I think you could stop a lot of human misery by just using the fucking regulatory authority that you have. Now, it's not, of course, as simple as all of that, because, you know, actually getting the determination process to stop is -- you know, it takes some time for the machinery to creak into gear. I'm sure that there would be lawsuits, you know, all of that. But --
Artie Vierkant 55:41
But at least do it.
Phil Rocco 55:42
Well I think --
Artie Vierkant 55:43
Like at least try.
Phil Rocco 55:44
But I think the point is just like, in terms of bang for your buck, policy wise, I think you're gonna get a lot further there. And the other thing is, if you don't ever use that authority, then sort of the strategy of exhortation, it doesn't really work. Like if you don't have some sort of a hammer that you at least bring down once in a while, then why would anybody believe the strongly worded letter, right? That's my bigger point about the policy. But the other thing is, I think, long-term, politically, if you're the Biden administration, you want to avoid blame for this. I think the point is, you have to like acknowledge that the program is part of the problem, and that the program's design, you know, it was an afterthought when Medicare was being created. It grew significantly through a variety of different mechanisms. But at the end of the day, it doesn't actually live up to the things that we say that -- you know, sort of the symbolic commitments anyway, that we've made about like what healthcare should be like. It's like, if it is the case, that we -- that at least symbolically, you're pointing to the idea that healthcare is some sort of right, then like how much sense does that really make when this number of people can be disenrolled at the drop of a hat, and when those disenrollments result in discontinuance, or delay of needed care, you know, all of these things, like the contradictions boil up, and you have to do something. And I think that if you're looking for like a hammer to hit it with, like ending procedural -- you know, ending procedural terminations in these states, or pausing them, and saying, we need to take a serious look at what is going on here. And basically, in the Code of Federal Regulations, it says, like when in doubt, interpret these rules in a way that maximizes the number of people who get this coverage, because that is the thing that we want to do. I think that that is a potentially valuable fulcrum, and I think that it actually would play into what Medicaid does. It would shift -- like the thing is, the spokesperson for the administration, or whomever that was said, like, oh, yeah, we're pretty sure that like red states are going to get the blame for this. Not if you don't actually try to do something to shift it there. You know what I mean? Like that's my -- and I'm not -- that's not with my Death Panel, like Medicare for All hat on. That's like my just be strategically sound in what the hell you're doing politically hat, you know? That just doesn't make any sense.
Artie Vierkant 58:18
Well, and by the same token, I mean, if again, put -- like donning the technocratic -- not the -- I don't want to mix metaphors about hats. I was gonna say donning the tech --
Phil Rocco 58:28
If we keep talking about these hats, we're gonna have to make different hats [laughing].
Artie Vierkant 58:31
Well, donning the technocratic, liberal hat, I guess, to mix this up and make it unnecessarily convoluted [Phil laughing], I think -- I mean, look, the reality is, back in June, when we last had like a whole big episode about this, right, our big takeaway from that conversation in June was literally, what the fuck are you waiting for? You have statutory authority at Centers for Medicare and Medicaid Services to intervene, to stop these procedural disenrollments. We already saw, we saw out the gate, the moment that unwinding started, we saw that a huge percentage of these disenrollments of the people getting kicked off Medicaid, were people are getting kicked off for these, you know, paperwork reasons, to collapse that into the term I was just talking about, right? We saw that from the jump. In June, what the Biden administration did was they put out this little like fact sheet, we talked about this at length in the episode. They put out this fact sheet called like, all hands on deck, like states should do this and that and the other thing to make sure that the burden of Medicaid unwinding isn't falling unfairly or disproportionately on the poorest and least advantaged among all the communities in your states, right, etc. That document, you know, we lambasted for leading with a Biden administration patting themselves on the back for declaring health care to be a human right, despite all of this stuff happening on their watch, and then, you know, touting the record low uninsured rate, etc. And, you know, whatever. That document was ridiculous and completely inadequate, and we called it out then. That was June. We've only gotten more confirmation over time that this continues to happen, that more and more people are losing coverage. CMS is still dragging its feet, the Biden administration is still dragging its feet. They have, as we have been talking about over the course of this episode, you know, a couple weeks ago, they put out this list of the -- all the letters that they had sent to Medicaid administrators saying, hey, now, you know -- I wouldn't even -- I would hesitate to even call them strongly worded letters. They're fucking politely worded letters. They include acknowledgement, like, oh, I know it's so hard to do this stuff, but you know -- like I'll just literally -- here, let me read a thing from it. This is form text that is in most of the letters, I'll say. "While CMS recognizes the significant steps that states have taken to prepare for unwinding and simplify renewal processes, we urge you to take further action to reduce the number of terminations for procedural reasons as quickly as possible," etc., etc. Ending that paragraph in pointing to the fucking tear sheet that they released in June that we were making fun of in that episode, there's still -- my point is, we're still very much in what the fuck more do you need to see territory. I do not buy, based on the way that they have been acting, that the Biden administration is considering taking any big action, like forcing states to pause their unwinding, or pause their procedural disenrollments, in the way that they have statutory authority to do so. I do not buy that they're doing that. I think, even though this has been projected by the Biden administration, clearly, to the press as them taking strong, decisive action, and then trying to like beat their chests a little bit and show like, we will use our authority, if we have to, I think the real threat, or I think all that they seem to be realistically threatening is that they will reduce the enhanced FMAP contributions prematurely, maybe, in some states. I know that's gonna -- like to some listeners, that's gonna sound like overly complicated, but that's like the specific, extremely small thing that I think that they're actually threatening to do here.
Beatrice Adler-Bolton 1:02:38
Which I feel like would just make this work faster, right?
Artie Vierkant 1:02:42
It's not gonna do anything.
Beatrice Adler-Bolton 1:02:43
Because part of the reason why the states are rushing this stuff is because they the FMAP money is sundowning and gradually getting smaller and smaller as the year progresses. So what, that's a good way to punish people by making it go fucking faster? What the fuck is that supposed to do to help people who are getting kicked off of their insurance?
Artie Vierkant 1:03:00
I digress though. Like I didn't want to take us like too far into a policy hole.
Phil Rocco 1:03:07
No, no.
Artie Vierkant 1:03:07
But like, I think that in this environment of like, again, what more do you need to see to take actual action against this, to actually use your authority to stop this, in this scenario, continuing to not act will compound the harms here.
Phil Rocco 1:03:25
Yes.
Artie Vierkant 1:03:26
Because as this progresses, the longer that the Biden administration drags their fucking feet on this, the more of these disenrollments will be completed. Already, 5 million or more have, and this is, again, time delayed data, we're only seeing the picture of data as it gets like reported from the states and then reported publicly, right? So the longer that this goes on, the more harm and the more severe the impact of this, and it makes no sense even from a like ridiculous, liberal technocratic standpoint. It makes no sense to wait.
Phil Rocco 1:04:02
Well, I mean, I think that, just to go back to my sort of theme for this episode is like, there again is the contradiction, right? Like the federal government has -- this program, Medicaid, is often described as a program of "cooperative federalism," right. And I think the way that that gets inscribed into the relationship between CMS and the states is that the approach that CMS often tries to use with the states is one of cooperation where, you know, here's what you have to do, we're going to tell you how to do it, we're going to make it easy for you to do, but it really does contrast with the fact that there is a huge body of regulations, because it is a national program where the federal government pays 72%, at this point, of the money and it's like, okay, yes, you -- yes, I understand that there's this concept of cooperation, but you also have a lot of regulatory authority and when people are being disenrolled in violation of the law, it's not just a question of like, do you use the regulatory authority, it's you have to, right, because you could actually get sued if you don't. And I think that the -- you know, that's like one important contradiction. The other one, I think, is the contradiction of like we're going to have a continuous expansion, inexorable march towards like the expansion of health insurance in the United States, but at the same time, we are going to tie state's hands to some extent, because the extended FMAP was, you know, in the year end Appropriations Act, the floor was cut out of it. And so, this is actually creating fiscal pressure on the states to do these disenrollments. And even if you say that they can't do them, which would have -- it would have legal effect. I mean, of course, it would be challenged in court. You could absolutely expect that. But it would have, you know, there's a really good argument that it would have legally binding effect. Even if that were true, states would have to find other ways of cutting Medicaid spending. And what they would probably do, if the past is any guide, is they would limit the kinds of services that were covered or -- and/or there will be a haircut to provider reimbursement rates, both of which are bad, you know. So my thing is like, look, do not pretend that the contradictions don't exist. Embrace them, right? Push on them. Reveal them. And actually, I think if you do that, I think that that's strategically wise, for political reasons too. I mean, I think it's not just like good -- it's not good policy, because the only way that these things actually get solved in the end is if the contradictions become clear, and there's enough kind of muscle there politically to redress them. They don't become solved when you just say like, everything is great and there's a right to health care in the United States. And you don't actually create any kind of -- you know, by doing all of this blame avoidance, I think it ends up backfiring at some point, because, at the end of the day, people's lives do get worse when they get disenrolled. Like that's the broader point.
Beatrice Adler-Bolton 1:07:10
Yeah. And people die, people get saddled with medical debt. I mean, yeah, let's say you get disenrolled from Medicaid, and you have a huge bill, and then you get back on Medicaid. Yes, you can submit the bill to get retroactively reimbursed, but you've still had to pay upfront, you're still going to be hounded by debt collectors, it can take a really long time for that to happen, or you're never paid, or it's never rectified. The harm is fucking done. Like the train is out of the station, it's moving. And there are so many people, there are millions of people standing in front of it. And like, they're just sort of sitting there saying, we're urging you to press the off button on the engine. We're urging you. And ultimately, when they sort of are framing these things, you know, this is again like the kind of issue also in the CDC masking recommendations, you know, the kinds of ways that we've seen the pandemic sort of taken from universal recommendations to individual recommendations has also sort of seen a shift from like, prescriptive to evaluative language, right? Like when we say we urge you to stop fucking torturing people with health insurance products, right? Like that is offering someone, you know, who is supposed to be making that decision, an evaluative opportunity to decide what to do, right, like you're being urged, you're not being told to do something. Masks are suggested, that's up to you, right, that's evaluative. That's not prescriptive. And the thing that's so fucking frustrating is that whenever it comes to talking about Medicaid procedural disenrollments, and disenrollments in general, you know, you always hear about, well, and so and so who got kicked off of Medicaid can't continue their prescriptions, right? Like the number one reason why people are "noncompliant" with their prescriptions is because they can't fucking pay for it. Because insurance is expensive, because health finance is a fucking extractive racket, right? And so, you know, we have this idea that, your health is your priority, you've got to maintain your labor power, you gotta keep yourself healthy, so that you can go to work, so that you can pay your premiums, so that you can keep a roof over your head, whatever. And these kinds of -- these kinds of frameworks, as they sort of build into the Medicaid system, like Medicaid begins to structure your entire life. It produces anxiety, it makes you depressed, it makes you feel worthless. The way that Medicaid treats you when you're disenrolled has been described as brutal, disorienting, depressing, makes people absolutely fucking miserable. It makes them feel worthless, it makes them feel unwanted by the United States, not a part of the body politic. I mean, there is so much about just the way that Medicaid works too, that makes you feel shitty when it's working right. But when it's not working right, when you're getting kicked off, when you're facing bills and dangerous times without your medication, non-coverage for your family, how the fuck is that supposed to make you feel about anything, right, or your worth or value or any of that? And to think that, oh, well, this is just sort of in a vacuum. Oh, people talking about, you know, Medicaid unwinding, they're really kind of blowing it out of proportion.
Artie Vierkant 1:10:25
‘Everyone will just get Obamacare plans.’
Beatrice Adler-Bolton 1:10:27
Well, yeah. And the accusation of like, oh, well, you know, if you talk about it that way, then it makes it seem like a done deal, and people give up, and they don't fight back. And it's like, what the fuck do you think you're doing? You know what I mean?
Artie Vierkant 1:10:41
Sorry for describing reality, yeah.
Beatrice Adler-Bolton 1:10:44
Yeah, ultimately, you know, the very process, right, of facing redetermination is oftentimes something that makes people give up. We know administrative burdens cull uptake, cull use, cull participation, by design, right? And so why are we surprised at the end of the day when people feel disenfranchised, abandoned, devalued, worthless, sacrificed for the economy? You know, it's not bad vibes chasing Biden's tail. It's the fact that he ran on promising increasing insurance for 15 to 20 million people through his bullshit fake, we don't need Medicare for All, we need a public option. Let's lower the Medicare age to 60. Let's expand Medicaid. Let's increase subsidies for ACA plans. I mean, my god, you're then going to preside over the disenrollment of 14 to 24 million people for Medicaid. Sure. Great. Good job. Job done. It's just [heavy sigh], no one should be surprised that shitty programs make you feel shitty about the government, right. But to claim, you know, oh, the project, we have to build trust, you have to rebuild trust in the face of the pandemic, we got to transition people onto these plans, you know, perhaps the way to do that is to make it seem like you actually care that people are getting kicked off of Medicaid.
Phil Rocco 1:12:07
Yeah, avoidance is a really -- I mean, I think that's the one -- I mean, risk aversion in politics is almost like universal. But I think it often -- like risk aversion gets tracked as like, well, we're just going to pretend it's not happening. I think that is precisely the worst thing that you could do. If you really care about this, you actually have to go on the attack with the power that the federal government has, you know, you don't get to get out of that.
Artie Vierkant 1:12:39
Yeah. So again, what are you waiting for?
Beatrice Adler-Bolton 1:12:42
Yeah, I think that's a great place to leave it for today. To support the show, become a patron at patreon.com/deathpanelpod, to get access to our second weekly bonus episode. And if you'd like to help us out a little bit more, share the show with your friends, post about your favorite episodes, pick up a copy of Health Communism, or preorder Jules' new book, A Short History of Trans Misogyny, at your local bookstore, or request it at your local library, and follow us @deathpanel_. As always, Medicare for All now. Solidarity forever. Stay alive another week.
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Transcript by Kendra Kline. (Kendra is currently accepting freelance transcript work — email her if you need transcripts!)