Obamacare ended the year with about 2 million people who signed up through the insurance marketplaces and maybe three times that many who signed up for Medicaid. That makes the Medicaid expansion a big success, but neither party really wants to admit it:
To Drew Altman, president of the Kaiser Family Foundation, this exposes a core reality of U.S. health-care politics. “Republicans don’t like entitlement programs, and Democrats want to portray the ACA as mostly a marketplace solution based on private insurance and not another expansion of a government program,” he said, “so neither side wants to emphasize the ACA’s success enrolling people in Medicaid even though it may be the law’s biggest achievement so far in terms of expanding coverage.”
This has left both the Obama administration and Republicans in a tight spot. The White House can’t really tout the Medicaid expansion because it’ll revive fears on the right that Obamacare is really a stealthy effort to create a single-payer health-care system, and it’ll arouse criticism on the left that the administration should have expanded Medicaid to all.
As for Republicans, they can’t admit the Medicaid expansion is going well because doing so is dangerously close to advocating a single-payer health-care system. The exchanges, marred by their troubled introduction, are also a problem as they are a Republican idea, enshrined in Rep. Paul Ryan’s health-care bill.
I think I’d analyze this a bit differently. I don’t really have a sense that much of anyone associates Medicaid expansion with a push for single-payer. Rather, Democrats don’t want to talk about it because Medicaid is a program for the poor, and they don’t want middle-class voters thinking that Obamacare is just another way to funnel their tax dollars into welfare programs for other people. Likewise, Republicans oppose Medicaid expansion simply because they don’t like entitlement programs; they don’t like higher taxes; and they’ve always wanted to block-grant Medicaid and starve it to death. I don’t think it’s really any more complicated than that.
In any case, I’m fine with this. I think Medicaid expansion is great, but unlike a lot of lefties, I also think it’s a dead end. It’s not going to lead to single-payer, and it’s never going to be a template for future health care reforms. The marketplaces, despite all their problems, have far more potential to eventually lead to health care coverage for all. I think they also have more potential to produce delivery reforms down the road and to rein in cost growth. For that reason, I’m OK with the Medicaid expansion staying under the radar. That’s a fine place for it.