Health Care/Joan Retsinas

Shrinking the Insured/Uninsured Schism

We are a nation of schisms. In COVID-world, the  two factions line up: vaccinated and not. The gap persists, even though Republican honchos in the COVID hotbeds, like Gov. Asa Hutchinson (R-Ark.)  and Sen. Mitch McConnell (R-Ky.), have urged residents to get vaccinated.

Two governors have upped the plea: Kay Ivey of Alabama blamed the unvaccinated for the recent surge of COVID cases; Jim Justice of West Virginia said vaccine-spurners were entering a death lottery. Yet the pleas have not swayed their resolute constituents.

Similarly, we divide politically: the ever-Trumpers who cling to their mascot vs. the rest of the country, eager to move beyond Jan. 6. We divide by race. Sixty-seven years after Brown v. Board of Education of Topeka, 56 years after the first Voting Rights Act, 53 years after Fair Housing Legislation, we emerge fiercely segregated. Then there is urban/rural; evangelical Christians/everybody else; pro-choice/anti-choice. The list goes on. One nation undivided cleaves into factions.

How refreshing to watch the insured/uninsured gap closing slowly, thanks to Presidents keen on shrinking the gap.

The gap has persisted since the early 20th century. Blue Cross plans, hatched during the Depression as a way to funnel money to keep fledging hospitals solvent, depended from the start on negotiations between hospitals and employers, starting with the Dallas school system and a Dallas newspaper. During World War II, the government insured families of soldiers, as well as veterans. Medicaid focused on women and children with low-enough incomes. Medicare saved the day for citizens over age 65 and disabled. Later, Medicare encompassed patients on kidney dialysis. The subsequent rollout of private insurance permutations — Health Maintenance Organizations, Preferred Provider Organizations — again recruited groups, mostly corporate employers, though groups could be unions, business coalitions, trade associations. The “individual market” plans, open to people outside groups, have been expensive, often with hurdles like restrictions on “pre-existing conditions,” “waiting periods,” low caps on payments. Just as we have accepted structural unemployment, we have accepted structural uninsurance as inevitable.

Nobody is proud or happy to be in this sector. While some Americans may flaunt their status as “unvacccinated,” and may identify solely by ethnicity, or religion, nobody exults in having no insurance. The Americans who rail against Uncle Sam’s involvement, who urge slow cautionary little steps, who want to defer to states, are the Americans who are insured. The uninsured want help.

So let us cheer — in this season when cheer is elusive — the gradual shrinking of  the insured/uninsured schism.

Go back to 2008, when 44.2 million non-elderly Americans had no insurance (17.1%). By 2010, 46.5 Americans (17.8%) were uninsured. Enter the Affordable Care Act a.k.a. Obamacare in 2010. The number dropped to 26.7 million (10%) in 2016. Then, in 2019, it rose to 28.9 million (10.9%). President Trump scorned Obamacare. His administration fought it in the courts; and he cut back on outreach. The pandemic forced into action the CARES Act, which gave money for COVID testing, COVID treatment, telemedicine — but not for insurance. The “uninsured” rate was curving up.

Enter President Biden. The American Rescue Plan authorized Special Enrollment Periods; and several states have expanded their own Special Enrollment Periods. He has pushed for legislation to reduce the health premiums for “marketplace” plans. The federal and state marketplaces, now open for business, are reporting increased numbers. States that gleefully rejected the option of expanding Medicaid — an Obamacare lure — are reconsidering. To date, 12 states remain steadfast in their “no,” but those states’ legislatures are debating. In 2021, Arkansas, Oklahoma, and Wyoming opened wider their Medicaid gates.

Without Uncle Sam, the insured/uninsured schism won’t shrink. Consider Alabama, which has not expanded Medicaid. If it did — more optimistically, once it does, 240,000 more residents will be covered.

The numbers are rolling in, state by state; the curve, once creeping up, is slowly creeping down.

Progressives lament the slow creep: without national health insurance, they say, we may never eliminate the gap; yet after four dismal years, let us cheer pragmatism.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email retsinas@verizon.net.

From The Progressive Populist, September 1, 2021

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