--:-- [Upbeat music fades out]
--:-- Sean Rameswaram: Hello! You're Jamal! Yes! Sean! Remember me? Yeah, absolutely! I came in here, we talked about mattresses? Jumping on the floor, on my bed. That's okay, right? When you jump on the mattresses? Absolutely, yeah, yeah, yeah. I'm back. You're good. I wanted to talk to you about mattresses a little more. Mm-hmm. Is that okay? Sure. Okay.
--:-- [Sound of a store in the background]
--:-- Sean Rameswaram: Back in 1965, LBJ created a program that would give poor people health insurance. It was called Medicaid. Millions do not now have protection or security against the economic effects of sickness. and the time has now arrived for action. And for the vast part of its history, it was restricted to people who were low income and something else.
--:-- Sarah Kliff: So low income and disabled, low income and a parent, blind, older.
--:-- Sean Rameswaram: Back in 2010, Barack Obama tried to ditch a lot of these restrictions. The Affordable Care Act, otherwise known as Obamacare, came along and it attempted to expand Medicaid to everyone who was under a certain income threshold. And the federal government will give you a 100% match, meaning the state won't have to put out any outlays and your citizens will be insured. No more of these categories. Obama wanted anyone in America making under $16,000 or so to get Medicaid.
--:-- Sarah Kliff: The Supreme Court stepped in and said, not so fast. I have the announcement in case number 11393, National Federation of Independent Business v. Sebelius, and the related cases. I don't know if you remember, in 2012, there was a big Obamacare Supreme Court decision around the individual mandate.
--:-- Sean Rameswaram: I remember. Thousands waited for the decision outside the court this morning. Then came word the health care law had been upheld by a five to four vote. So the kind of B-side, lesser known part of that ruling, the surprise ruling for everyone in the health care world.
--:-- Sarah Kliff: We now turn to the second part of the act challenged in this case, often referred to as the Medicaid expansion. And this was kind of seen as like a nothing burger challenge. No one was really worried about it. Everyone was talking about the mandate. But the Supreme Court, it upheld the mandate, but actually said that the expansion of Medicaid in the Affordable Care Act is unconstitutional to the extent it allows the federal government to take away a state's Medicaid funds if the state does not adopt the expansion. That's a state decision. It's too coercive. So we are turning this decision over to you, the states, if you want to expand Medicaid to cover lots more low income Americans.
--:-- Sean Rameswaram: And that's why we kind of have this patchwork situation of today. 70 million-ish Americans get their health insurance through Medicaid today. One out of five. And it's easier to get on the program in 34 states, the ones that expanded the program along with Obamacare.
--:-- Sarah Kliff: A lot of states didn't like Obamacare, as you may remember, and didn't want anything that came along with it, i.e. Medicaid expansion. But now that Obama's out of office, some of these remaining states are coming around. Kind of the idea is Obama's out of office. It feels less like Obamacare. It's just some federal program that gets people health insurance.
--:-- Sean Rameswaram: Layered on top of that, you have the fact that it seems like for the time being the Affordable Care Act is here to stay. So you have this combination of Obama being out of office, the failed attempts at repeal that are giving states more confidence to pursue Medicaid expansion in 2018.
--:-- Sarah Kliff: And the four states that have approved Medicaid expansion are Virginia, Nebraska, Utah, and Idaho. Three of those are looking at doing something kind of unusual. They're looking at using a ballot initiative to expand Medicaid. So essentially asking their state residents to vote. Do you want this benefit in our state? And why the ballot initiative?
--:-- Sean Rameswaram: You said it's going to be like a state referendum in three of these states? Yeah. So this is something that was tested out for the first time in 2017 in Maine and was successful.
--:-- Sarah Kliff: Maine in 2017 became the very first state to expand Medicaid by ballot initiative. And it won by a pretty wide double digit margin. OK. Maine is sending a strong and weighty message to politicians in Augusta and across the country. We need more affordable health care, not less.
--:-- Sean Rameswaram: Now, there are some complications there. the governor, Paul LePage, has refused to implement the ballot initiative, so people in Maine have not actually gained Medicaid at this point.
--:-- Sarah Kliff: When able-bodied people who are able and should be working choose not to work then I think it society responsibility to cover their insurance at the expense of our mentally ill our disabled and our elderly
--:-- Sean Rameswaram: But the idea that you could expand it if you did not have a governor that was very obstinate on this kind of caught on in other states. So you see states, places like Idaho, Utah, Nebraska, where either the legislature or the governor, you know, has not wanted to expand Medicaid. Yeah, this is kind of a, you know, workaround, a way to expand Medicaid when you can't get the legislature to sign off on it.
--:-- Sarah Kliff: You can go to the people in the states that have that kind of ballot initiative process. So right now we know that the ballot initiative, it's qualified for the ballot in Utah. We're pretty sure it's qualified in Idaho. We're waiting for the state to certify that in Nebraska. They're gathering signatures up until July 6th, and then we'll see if they get enough signatures.
--:-- Sean Rameswaram: There's also an effort in Montana because their Medicaid expansion sunsets in 2019 to extend it again through ballot initiatives. So this will be a huge thing that I'm watching in November is how people vote on these ballot initiatives. Are people clamoring for this Medicaid expansion?
--:-- Sarah Kliff: I mean, like, what would happen if it didn't go through in any of these states? So I think you see the clamoring kind of on two levels. One is from like the progressive organizer space where, you know, people who support the Affordable Care Act, they've really turned to these ballot initiatives as the next way they can keep getting more people enrolled in the Affordable Care Act, even as everything's happening in Washington.
--:-- Sean Rameswaram: This is something really tangible they can do right now. And then you have the actual people who would be affected by this. Americans who are earning less than $16,000 or so per year, they stand to gain a lot from enrolling in Medicaid.
--:-- Sarah Kliff: We have pretty decent data at this point suggesting that you see lower death rates among states that expand Medicaid compared to states that don't. You see greater access to health care services. You see less medical debt among this particular population.
--:-- Sean Rameswaram: So you certainly do see changes when Medicaid expansion comes into effect. So of these four states that are pushing this through soon, Virginia, Utah, Nebraska, Idaho, which one's the closest? Virginia is definitely at the lead of the pack right now.
--:-- Sarah Kliff: So Virginia's governor, Ralph Northam, last week, he signed a bill from the legislature to expand Medicaid. So Virginia is the one state in 2018 that is looking to expand through the kind of normal legislative process, not a ballot initiative, but just going to legislature.
--:-- Sean Rameswaram: You know, I'm just a bill up on Richmond Hill, I guess, in Virginia. And I'm going through that route. So this has been a years long effort for years. Virginia has had a Democrat governor, but a Republican controlled legislature. And they could never agree on this.
--:-- Sarah Kliff: The Democrat governor, the last one, Terry McAuliffe, was just always a few votes shy of getting it over the finish line. You know, as governor, I sit at this desk and I use that phone behind me all day long competing against all these states today to bring businesses to Virginia.
--:-- Sean Rameswaram: And unfortunately, the House leadership is letting an extreme Tea Party ideology overtake what is a smart business decision for Virginia. And each year as a reporter, I would kind of watch and they would debate it and it just like would get close, but wouldn't get there. But it did last week. Health care. 400,000 low-income Virginians will be able to get Medicaid.
--:-- Sarah Kliff: After years of gridlock, the General Assembly expanded Medicaid coverage in this year's budget. Several Republicans crossed party lines to get this all done. What changed? What was the shift?
--:-- Sean Rameswaram: Three things going on. First, Democrats won a bunch of seats in the Virginia legislature in the last election. That's step one. Step two, President Obama no longer in office. It makes Medicaid expansion a little bit more palatable politically.
--:-- Sarah Kliff: Step three, though, is something that progressives probably don't like, is that in order to expand Medicaid, they have decided in Virginia that they are going to require people on Medicaid to work to receive that benefit. What? Yeah.
--:-- Sean Rameswaram: So this is kind of the other side of what's happening in Medicaid this year. On the one hand, you have real momentum behind expansion. But on the other hand, you have the Trump administration for the first time opening up the door to these requirements that people who receive a Medicaid benefit have to prove to the government that they are working.
--:-- Sarah Kliff: And that's really what got the necessary Republicans on board in Virginia. And it's not just Virginia. There's four states right now, aside from Virginia, that have approved work requirements that are starting to take effect this summer.
--:-- Sean Rameswaram: So it's glass half full, glass half empty, and which side is full or empty kind of depends which side of the debate you're on. Good news. If you're really poor and out of work, you can finally get Medicaid in a bunch of new places. Bad news. If you want the Medicaid in some of those places, you're going to need to work for it.
--:-- Sarah Kliff: How does that work? That's in a minute on Today Explained.
--:-- Sean Rameswaram: Jamal we here at Mattress Firm in DuPont Circle in Washington D You got a lot of mattresses here
--:-- Jamal: How many mattresses would you say you have here I have 14 on the floor Okay. And I have about 10, 11 of them on rack.
--:-- Sean Rameswaram: And what kinds are they? You mean brand? No, like firm, soft, large, small, queen, king. What do you got? All. We have all price range, all comfort levels.
--:-- Jamal: Okay. Yeah, you can be starting from $1,999 for a coin up to $5,000. Wow, yes. And outside, I saw a sign outside that said 0% financing available. Absolutely, yes. Zero interest. I mean, like a payment program, it really is cool. You don't pay any pennies. It's free. Yeah, zero interest.
--:-- Sean Rameswaram: And have you heard about the coupon code PODCAST10 when you go to mattressfirm.com and you get a mattress there too? Absolutely, yes. 10%. What's your favorite podcast, Jamal? Today Explained. Thanks, Jamal. Today, Today Explained. Today Explained.
--:-- Sarah Kliff: So I'm a little confused. You're really poor. You're making less than $16,000 a year. And so you need Medicaid. Probably because you can't find work. But if you're going to get this benefit in Virginia, you need to work for it. How does that work? Yeah, so this is, you know, something that's never really been tried in Medicaid before. It's totally new.
--:-- Sean Rameswaram: And this is something conservative states have wanted to try for a while. There's been this argument that Medicaid, it is a health care benefit, but it also should be helping people get back on their feet. It should be a temporary program. It should not be the health insurance you have for your entire life.
--:-- Sarah Kliff: And one way they are going to push in that direction is by requiring people to work to have this benefit. States asked for permission to do this during the Obama administration. The Obama administration routinely said no. The Trump administration reversed course pretty quickly and said yes.
--:-- Sean Rameswaram: Tonight, the Trump administration issuing this memo to Medicaid directors all over the country, encouraging states to start requiring able-bodied Medicaid recipients to work or volunteer in order to keep their health insurance coverage. It's a move that impacts millions.
--:-- Sarah Kliff: There are four states now, Indiana, Kentucky, Arkansas, and New Hampshire, that have approved work requirements. There are seven additional states that have applications in to create work requirements. And that actually doesn't even include Virginia yet.
--:-- Sean Rameswaram: Now that Virginia as governor has signed the law, they have to kind of add their request to the stack. And actually just last week, so you kind of have this really two big different things happening. You have Virginia saying we want to expand Medicaid. And then Arkansas just enacted June 1st, the country's first ever work requirement in Medicaid.
--:-- Sarah Kliff: This is not about punishing anyone. It's about giving people an opportunity to work. What do you have to do? Do you have to show up to like government supply jobs? I mean, if there aren't jobs, where do you find the work? We're just going to start learning the answers. You know, we're literally, you know, a week and a half into the first work requirement.
--:-- Sean Rameswaram: And we are at the start of a huge experiment here. Governor Asa Hutchinson says Arkansas works enrollees who are 19 to 49 years old must report 80 hours a month of work, school, volunteering or job searching.
--:-- Sarah Kliff: Arkansas is definitely one of the more restrictive work requirements in the country. So the way that theirs works is you have to prove to the government that you are working 80 hours a month. And if you don't do that, you could lose your Medicaid coverage for three months.
--:-- Sean Rameswaram: You have three failures to prove that you are working in one year. Then you can't apply again until the next year. So it's kind of a three strikes you're out policy in Arkansas.
--:-- Sarah Kliff: And I should say the requirements typically only apply to able-bodied Medicaid recipients. So if you are someone who has, for example, a medical condition that prevents you from working, which might be pretty common on Medicaid, or you are a new parent, you are pregnant, you are a caregiver in some capacity, there are exemptions for those people.
--:-- Sean Rameswaram: But you have to submit that paperwork. So that's kind of the landscape in Arkansas right now. And we don't know what it's going to look like in a month. You know, advocates definitely are worried people are going to fall off the rolls there.
--:-- Sarah Kliff: And, you know, we've seen even like Kentucky, which was the state that really kind of led the charge on work requirements. Their governor, Matt Bevin, is a huge supporter. It's insulting to keep people as third class citizens.
--:-- Sean Rameswaram: And it is now nearly a third of those in Kentucky. It's not acceptable. I don't think that it's appropriate. Kentucky has said, you know, they expect fewer people to be on Medicaid after they implement their work requirements.
--:-- Sarah Kliff: Governor Matt Bevin office estimates the plan will save Kentucky almost two and a half billion dollars over five years and reduce the Medicaid rolls by some 100 people But we don know who those people are who fall out of the Medicaid program
--:-- Sean Rameswaram: And this doesn't necessarily mean these are people who no longer need health coverage. It just means that these are people who no longer qualify? Yeah. Or they're people who maybe do qualify but didn't get the paperwork right, who, like, you know, didn't get the signature from their job. that they worked 80 hours or didn't file the paperwork correctly to show that they were pregnant and qualified for an exemption.
--:-- Sarah Kliff: What even qualifies as work then? I mean, if you have to work 80 hours a month in Arkansas, does babysitting your friend's kid for like 40 bucks on a Friday night count? How is this measured? How how is the work going to be rubber stamped and validated?
--:-- Sean Rameswaram: I've talked to some Medicaid recipients in Kentucky who raised this exact issue. For example, one woman I talked to who left her job because she kind of had severe vertigo. So she wasn't really sure if she'd qualify for an exemption or not.
--:-- Sarah Kliff: And she just said, you know, she doesn't have a car. There's no public transit where she lives. And there just aren't a lot of jobs. So then, you know, the state says, well, you can volunteer. And she says, well, just getting to the place that is going to give me a volunteer opportunity, I don't even have the resources to do that right now.
--:-- Sean Rameswaram: I will say one state did try to attempt to solve this problem, but did so in an incredibly, it turns out, pretty racist way. So Michigan was looking at a work requirement and still is looking at a work requirement. And they said, OK, what we're going to do is we're just going to exempt counties that have an unemployment rate over 8.5 percent.
--:-- Sarah Kliff: That it kind of signals, you know, there aren't enough jobs here. It'd be unrealistic to ask somebody for a job. Turns out if you start looking at, well, where are the places that have high unemployment rates? They are all rural, predominantly white counties.
--:-- Sean Rameswaram: If you go to Wayne County, which is predominantly African-American, it has a low unemployment rate and the people there would be subject to the work requirement. So essentially, you know, when you start using that unemployment cutoff in Michigan, and I think you'd probably see this if you looked at a lot of other urban-rural divides, you'd have a work requirement that would largely just apply to black Medicaid recipients.
--:-- Sarah Kliff: What's the motivation behind these work requirements? Are people taking advantage of Medicaid? One of the things I've really seen in my reporting in some of the areas that really favor Medicaid expansion is there's a perception of people on Medicaid as very lazy and undeserving.
--:-- Sean Rameswaram: So I spent a lot of time in Kentucky reporting on Obamacare in 2017. and one of the things, you know, really unprompted that would come up in a lot of my interviews was the sense that people on Medicaid, they don't really work. They get this great benefit because when you have Medicaid, you don't have to pay to go to the doctor. You don't have a copayment. You don't pay when you pick up drugs. It's actually people who have Medicaid really, really like Medicaid, and I totally get why.
--:-- Sarah Kliff: But this actually led to a lot of resentment from people who earn too much to qualify for Medicaid, for people who actually buy the Obamacare plans, which have really high deductibles, like $6,000 deductibles. Then they look at someone who maybe isn't working or who's working fewer hours than them or is working a low-wage job, and they say, why does that person get this? They should have to do something.
--:-- Sean Rameswaram: I work so hard and I get a plan I don't really like. So the tensions around this, I think they speak to some larger questions that we in the United States haven't resolved about who deserves health care.
--:-- Sarah Kliff: If you want to have robust conversations about health care policy on the regular, Vox has the Facebook group for you. You can find it at facebook.com slash groups slash vox.com. But you're going to want to spell out vox.com.
--:-- Sean Rameswaram: Jamal, when you're at mattressfrom.com slash podcast using the coupon code podcast10 or here in the store, what's the most important thing when you're shopping for a mattress?
--:-- Jamal: well there are two things support level how much sport level and one is comfort levels when you're talking about sport levels how the engineering matters how much how much amount of coil in it what are the layer of the latex in it that's to give you a good sport when we're talking Now comfort, what memory forms. Yeah, there are all kinds of memory forms in it. Also, there is temperatures management in there too. They regulate your temperatures. Wow, so you've got a mattress for just any kind of human being. Absolutely, yes, anyone. Beautiful.
