It is not only pre-existing conditions – Medicaid is also on the ballot

CHELSEA, Mich. – People who depend on the protection of the law on affordable care for people with pre-existing disorders have a lot to lose with the elections on Tuesday. But people who depend on Medicaid also do so, even though they have received much less attention during this election cycle.

Aaron Robertson is one of those people. Robertson, 35, lives in Chelsea, Michigan, a town of about 5,000 people, about an hour's drive west of Detroit. He works in a downtown cafe and earns enough money to support himself, but not enough to get health insurance. He remained unhedged for many years until 2015, when he enrolled in the Michigan version of Medicaid.

It was a bad time, because a few months later, while helping his uncle perform maintenance work on a boat, he slipped on a 12-foot ladder and broke several bones in his foot. The treatment would eventually involve two separate surgeries, plus months of rehab.

It was painful except in the financial sense. Medicaid is busy paying bills, leaving him only a handful of expenses at his expense.

"I was lucky," Robertson told me in a recent interview on a rainy night just days before the election. Without Medicaid, he would have gone bankrupt and possibly permanently disabled because he would have skipped the follow-up care and probably the second operation, although the first procedure did not completely repair the damage.

"I probably could not work, I'm not sure what I would have done," Robertson said. "How can you afford anything if you can not work?"

Robertson was able to connect to Medicaid because Michigan is one of 33 states that, along with the District of Columbia, decided to take part in the extension of the ACA program.

This means that states have opened their Medicaid programs to anyone with an income lower or just above the poverty line, instead of limiting enrollment to narrowly defined groups such as children, pregnant women and disabled people. The federal government pays the bulk of the costs.

The effects were dramatic. According to official estimates, more than 680,000 Michiganders have been covered by this expansion. And it's emblematic of what has happened across the country.

In total, about 14 million people have taken out insurance due to the Medicaid extension. This is the main reason why the number of people without coverage has fallen to levels never reached since the ACA came into force.

But these gains could disappear, according to what will happen Tuesday.

If the Republicans keep both Houses of Congress, they will almost certainly try to repeal the ACA. And if the bill they are considering looks very much like the proposals they tried to pass last year, it will both remove the federal government's additional funding for the Medicaid expansion and reduce federal government expenditures for the remainder of the program.

Most states would respond by dramatically reducing their Medicaid programs, re-establishing their eligibility prior to expansion, and reducing services, even for traditional groups such as children and people with disabilities.

As the writer Andrew Sprung Recently, on the website healthinsurance.org, the Republican proposals "could permanently paralyze Medicaid".

An easy way to measure the impact is to look at people who would have lost coverage if the US Health Care Act, the repeal bill passed by the Republicans of the United States. House in 2017, was becoming law. Overall, the Congressional Budget Office concluded that the number of people on Medicaid would have decreased by 14 million, reversing the gains made in recent years.

That's a lot, obviously. But it is also significant.

Many studies, many of which are based on data collected over the last few years since the expansion, conclusively show that, compared to people without insurance, Medicaid patients are better off. This may seem obvious, but it is actually a question that conservative critics of the program, including some who hold important positions in the administration of President Donald Trump, have questioned.

Some of the most recent evidence of the effectiveness of Medicaid comes from Michigan, where researchers from University of Michigan found that people with Medicaid coverage were more likely to benefit from cardiac services, for example, and less prone to heavy credit card debts, evictions and bankruptcy declarations.

Nancy Paul, executive director of Faith in Action in Chelsea, does not need a study to inform her of the impact of this expansion.

For years, his organization worked with a local doctor and nurse to provide basic medical services to the poor. They stopped after the Medicaid extension took effect as they realized that it was no longer necessary. Potential patients would go to doctors, clinics and hospitals where they could be treated on their own, and Medicaid to cover the costs.

"It's really easy, after four or five years in this extension of the Affordable Care Act, to forget what it was for people," said Paul.

She especially thinks of parents who work and whose children meet the requirements of the old criterion but who have no means of paying for their own care. "If you are a single parent and you are trying to take care of your children and you are a decent parent, and you can not even go to the doctor, how can you do it? You are going to have big problems. "

More than a thousand miles away, in Boise, Idaho, Penny Beach tells a very similar story – with a critical twist.

Beach is medical director of the Idaho Family Medicine Residency, a clinic that serves uninsured patients in and around the city. She does not have to remember what she was before the Medicaid expansion, as Idaho is one of 17 states where Republican officials refused to take the federal government's extra money.

Since eligibility has not changed, most low-income people in the state are still not eligible.

Beach, who has been treating underserved populations for about 20 years, says she is sure she has seen patients suffer because clinics like hers simply can not provide the kind of specialized services patients need. Sometimes, she says, uninsured patients are afraid to come forward and be tested because they are so afraid of not being able to pay for care.

"I had to admit patients to the hospital, people in their 50s with heart attacks or strokes, because they had never been seeking care for their blood pressure or their diabetes, even if they they might have been able to find care, "Beach said. .

Diann Sivels-Sharrer, a 57-year-old home medical assistant, is one of Beach's patients. She tends to have a mother and a daughter with physical and mental disabilities, but she also has serious health problems, including a severe tear to the groin muscle that she thinks she had had while raising a Wheelchair.

She needs surgery, but she does not have it yet because she has no insurance and can not pay the bills. When I met her a few weeks ago at the Boise Clinic, she needed to get up and walk around to ease the pain.

Beach and Sivels-Sharrer are hoping for a change of fortune – and they could have one. Idaho is one of three deeply conservative states where activists took matters into their own hands and collected signatures for initiatives that would require states to accept federal money and develop Medicaid.

In two other states where Republicans blocked expansion, Florida and Georgia, Democratic governor candidates Andrew Gillum and Stacey Abrams pledged to push for an expansion when they were elected.

Medicaid has attracted a lot of attention in these states, because of the initiatives taken and because Gillum and Abrams have made them the center of their campaigns.

It is also present in other campaigns, among which Michigan governor racebecause the Democratic candidate, former Senator Gretchen Whitmer, contributed to the struggle for state expansion while her Republican opponent, Attorney General Bill Schuette, opposed it, although he recently stated that the expansion was "going nowhere".

But even some of the people who depend on Medicaid seem to understand that their coverage depends on the outcome of the elections – and that they have some power to determine this outcome.

Chelsea is part of Michigan's 7th Michigan District, and outgoing GOP incumbent Tim Walberg is standing for re-election. His Democratic opponent, the former state legislator, Gretchen Driskell, attacked Walberg for his vote on the repeal and pointed out that 49,000 people in his district had been covered because of his expansion .

In the past, Republican critics like Walberg have said that Medicaid was too expensive and that it is true that the program, like any government program, requires spending money that taxpayers end up paying for. One way or another. But Medicaid is at least cheaper than private insurance – and ACA, on the whole, offsets new government spending by combining higher taxes and cuts from other programs.

In any case, Walberg did not really present this argument. Like his Republican compatriots in the country, he tried to avoid this topic, which is not surprising since polls show that voters trust Democrats more than Republicans on health care. Driskell keeps the race tight, even though the district has a distinct Republican bias.

When we spoke with Anderson in front of the Chelsea café, I asked him if he knew the future of the Medicaid extension was compromised – and that it could depend, to a small extent, on people he and his other voters from Michigan sent to Congress. He said he did not do it, although he said he would do some research before voting.

"I really hope they will not take it off," he said. "It would hurt a lot of people."