5 Questions on the Midterms with Healthcare Expert Michael Sparer

October 29, 2018
Michael Sparer

Access to healthcare is at stake on Nov. 6, says Michael Sparer, chair of the Department of Health Policy and Management at Columbia’s Mailman School of Public Health. “The midterm elections will send a very strong signal as to whether the Republican agenda of the last few years will continue and expand, or if the country is pushing back.”

Republicans haven’t managed to repeal and replace the 2010 Affordable Care Act (ACA), but the law has been weakened. The 2017 tax legislation eliminated the penalty for not having health insurance, a provision of the ACA known as the individual mandate. And a 2012 U.S. Supreme Court ruling effectively made the Act’s requirement for states to expand Medicaid optional.

Sparer, who has a J.D. degree from Rutgers and a Ph.D. in political science from Brandeis, joined Mailman in 1991. He is the author of Medicaid and the Limits of State Health Reform, and former editor of the Journal of Health Politics, Policy and the Law.

Q. How will the upcoming mid-term elections affect the ACA?

A. If Republicans hold onto the Senate and pick up a seat or two, and manage to keep the House, they may well go after the ACA again. At the least you’ll see renewed efforts to cut back its scope. They’ll also try again to cap federal spending on Medicaid, which was part of the effort last year. If Democrats win the House, and certainly if they win in the Senate, there will be increased efforts to shield the ACA from attempts to reduce its impact, and an infusion of energy into the argument that going into 2020, Democrats should try to expand the scope of coverage. Many Democrats are proposing Medicare-for-all, and while the odds of that are slim, the proposal itself could aid more moderate efforts to encourage Medicare-for-more, either by lowering the eligibility age to 55 or 50, or by allowing all Americans to buy into the program.

Q. How does the end of the individual mandate affect these efforts?

A. Repeal of the financial penalty for noncompliance with the individual mandate takes effect in 2019. Initially, it was expected that without it, many young and healthy people would drop their insurance coverage. Those who remained presumably would be older and sicker, and premiums in the ACA’s insurance exchanges would rise significantly, leading even more people to drop coverage, a cycle that could eventually kill the exchanges. What’s interesting is that insurers, who don’t know exactly who’s going to sign up, apparently don’t expect such a scenario. At least part of the reason is that 85 percent of people who buy coverage through the exchanges have incomes low enough that their premiums are subsidized by the federal government. They may opt to stay insured. In fact, 2019 premiums in the ACA marketplace are now expected to decline in much of the country, which has resulted in some strange politics. Republicans continue to argue that the ACA is failing—except when they try to take credit for lower-than-expected premium increases.

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Q. Are there also issues at the state level?

A. Seventeen states have not adopted Medicaid expansion. On November 6, there are referendums in Idaho, Nebraska and Utah to require the expansion and voters are expected to approve all three. Montana has a ballot measure to impose a cigarette tax to fund continuation of their Medicaid expansion. There’s also a movement in 10 or 12 states to allow currently uninsured individuals to buy into the Medicaid program.

Q. You have written that Medicaid is a better path to universal coverage than Medicare. Can you explain?

A. I’m all for lowering the Medicare eligibility age to 50 and also for letting people buy into it. But over the last 30 years, Medicaid has served as an effective path to expanded coverage for millions and it now covers 75 million Americans. One reason is that the cost of Medicaid is shared by the states and the federal government and our political culture is more supportive of state-based programs. Timing is also important. Expanding Medicare requires that Democrats control both Congress and the presidency, which means 2021 at the earliest. States, however, can act now. There’s still a stigma attached to Medicaid. Doctors don’t like its low reimbursement rates, and there’s a lot of variation among the states in how the program works. Given the political context of American government, and lessons from the last 30 years, I think Medicaid is more likely to be our incremental path toward universal coverage.

Q. You teach courses on the history of U.S. healthcare. What will history say about the Trump era?

A. There is no doubt that the Trump administration will continue its efforts to slash the scope and size of publicly-funded health insurance programs. My guess is that they will not succeed. My hope is that we’ll look back on this era and see the unexpected resilience of these programs. The midterm elections will be an important chapter in this story.

—By Georgette Jasen