At the close of 2019, the polling firm Hill-Harris conducted a nationwide survey of registered voters and found that health care tops the list of issues they care most about. Of those surveyed, 15% said health care “is the most important issue facing the nation today.” To put that in perspective, national security and terrorism followed at 12%, immigration and the economy each polled at 10%, and climate change came in fourth, at 8%.
In a similar poll from September 2019, Fox News found that 57% of registered voters surveyed would like to see “minor changes” to the Affordable Care Act, while 46% supported eliminating private health insurance plans altogether. These statistics are staggering and could be alarming, if we fail to recognize and consider the opportunities (and responsibilities) for state policymakers in this area. Ever since Obamacare was passed in 2010, the right-of-center response focused on “repeal and replace.” At the state level, the battles often narrowed to building defenses against the perverse incentives Obamacare gives states to extend Medicaid coverage to able-bodied, single adults.
The cause of repeal has faded in Congress. And in states, legislators have increasingly caved to pressures to keep the expanded form of Medicaid and use so-called market-based approaches aimed at controlling costs.
Meanwhile, surveys show that voters across the political spectrum are concerned about health care access and affordability — and want changes that do some good. The disagreements appear when we talk about solutions, however. Michigan lawmakers who wish to respond to voters’ wishes in this election year have two opportunities to act on the consensus that some changes are necessary.
Reform Certificate-of-Need laws. These laws require health care providers to seek permission from a government board before opening or expanding their practices. They must prove to this board that their plans respond to a “community necessity.” Furthermore, they must also present their case before existing competitors, who are given an opportunity to contest the applicant’s plans. Research suggests that these laws reduce access and quality of care and can worsen patient health. Legislators should amend these laws so that patients in our state have the opportunity to receive the best and most affordable care. Repeal would ensure that rural residents — who are the ones most affected by these laws — do not face unnecessary hurdles to obtaining care simply because of where they choose to reside.
Freeze Medicaid enrollment for able-bodied adults. “Whatever that bill is, you have to cover it,” former Michigan state budget director John Nixon said of the Medicaid program. In 2010, Michigan was spending $1.5 billion more than it collected in revenue. Nixon was responsible for fixing this problem, but he was unable to touch Medicaid — which at that point consumed more than a quarter of the state’s budget. The result? Millions of dollars in spending on other state priorities, predominantly education, got cut. A similar story has played out across the 50 states. In the last three years, two-thirds of the extra revenue an average state collected went to Medicaid and pension liabilities.
Michigan lawmakers anticipated that Medicaid costs may become too burdensome when they expanded Medicaid enrollment by enacting Healthy Michigan about six years ago. So they included trigger language requiring the Legislature to revisit expansion if the projected savings from the program were no longer sufficient to cover the state’s share of its cost. This year, the federal government will stop paying 100% of the cost of expanded enrollment, so Michigan lawmakers must consider how the state will absorb the added costs. One responsible way to do that is to freeze enrollment for new, able-bodied, working-age adults. Keeping access to benefits for those who have already enrolled in the program will ensure they do not experience a disruption of coverage, while regular attrition of current enrollees will slowly rein in costs.
Expect to see these issues to take center stage for lawmakers considering meaningful health care reform in 2020.