The "Reconciliation Only" Option: Just Give Medicaid to Those Who Can't Afford Insurance

If the House Democrats can't find the vote for the Senate bill, and the Senate Democrats are too collectively ego-driven to support a reconciliation sidecar, then the only remaining strategy I can see for a significant increase in insurance coverage is to use reconciliation to just give most Americans who can't afford health insurance access to coverage through Medicaid, Medicare, or SCHIP. This is simple, clean, easy to explain, and a more cost-effective way to expand coverage. Not going this route in the first place was a huge mistake.

The Senate bill expanded insurance to 15 million Americans by increasing Medicaid eligibility for every American to 133% of the federal poverty line (FPL), and by maintaining the SCHIP program. That represented $395 billion of the total cost of the bill. The Kaiser Family Foundation concluded that roughly 30 million of the uninsured in this country are below 200% of the FPL. A recent poll by them also found that when people were told the bill would expand Medicaid to every family making less than $29,000 a year, 62% of voters said that made them more supportive of the bill, while only 22% said they were less supportive.

Expanding Medicaid to everyone below 215% of the FPL, and expanding SCHIP coverage to all uninsured children, should give roughly 30 million more Americans insurance for a cost of just under $800 billion, which is less than the Senate bill.

The Medicaid expansion could be structured to also work as a de facto extreme catastrophic insurance policy for people over 215% FPL. You could set it up so that if anyone suffered from a major medical emergency, which cost so much it effectively made their yearly income below 215% FPL, they would, at that point, be covered by Medicaid. This would effectively put an end to medical bankruptcy in this country.

Early Medicare buy-in could be added for people without insurance who are between 47-65. This is the group who, even if they have money, tend to have the toughest time finding affordable, quality health insurance.

Expanding Medicaid, Medicare, and SCHIP are all doable under reconciliation. A bill that does these three things would only need a simple majority in the Senate, would be cheaper than the current Senate bill, and probably be no more than 30 pages long. This strategy of simply giving people who can't afford insurance coverage through Medicaid and Medicare is extremely easy to explain. Also, these public programs are already covered under the Hyde amendment, so there shouldn't be objections from anti-choice Democrats like Bart Stupak. I don't doubt for a second that a 30-page bill that simply gave those without insurance Medicaid would be dramatically more popular than the current Senate bill.

Don't buy the lie that passing the Senate bill "as is" in the House is the only option. The Senate can adopt a reconciliation sidecar strategy, or they can do a significant coverage expansion even more cost effectively by using a reconciliation measure for a whole new bill. The problem is not reluctant House members or Senate rules. The problem is the Democratic senators themselves.

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