If a prize were given for the best story about Medicaid and the Affordable Care Act to date in 2014, it would go to The Atlantic for Olga Khazan’s “Living Poor and Uninsured in a Red State.”
Khazan’s piece, published in early January, explored the impact of the Supreme Court’s ruling that individual states could “opt out” of the Medicaid expansion envisioned by the ACA—an expansion that was originally designed to bring insurance to 15 million Americans. The “red state” in question is Texas, where Gov. Rick Perry is steadfastly opposed to expansion, calling it “a misguided, and ultimately doomed, attempt to mask the shortcomings of Obamacare.” Khazan’s article offers a look at the policy arguments for and against expansion. It quotes white papers and journal articles, cites statistics, embeds relevant maps and graphs.
And most importantly, it shares the experiences of a few of the roughly 1 million Texans who fall in the “Medicaid gap”—people who earn too much to qualify for the state’s existing program, but too little to get federal subsidies to shop in the new exchanges, because the ACA’s drafters expected them to enroll in the expanded Medicaid program. We meet MaGuadalupe, who has been putting off a $4,000 dental bill to help her son save for college, and Claudia, who nearly died of complications from gall-bladder surgery when she was reluctant to go to the hospital, fearing another bill. Then there’s Mark, who was able to start treatment for tongue cancer about a year after he first showed up at the ER with symptoms. Ideally, that process takes less than three months.
With Texas home to more than a fifth of the uninsured Americans in the “coverage gap,” and the volumes of media attention devoted to the Affordable Care Act since the fall, you might think that the state’s news outlets have been full of stories like these—especially in the first months of this year, with expanded coverage beginning Jan. 1 in some states.
That has not been the case. It’s not that the Medicaid expansion debate has been ignored. It’s that it’s been covered through the frame of institutions and arguments: budget analyses or advocacy campaigns or healthcare providers or op-eds by politicians. With a few exceptions, like this Dallas Morning News column, the actual experiences of low-income, uninsured Americans have been mostly absent.
But this isn’t only about Texas! Zoom out for the nationwide picture, and you can find some strong reporting that takes a deep look at the struggles faced by people stranded in the coverage gap, like this story from the Kansas Health Institute News Service, or this one from KSMU in Missouri, or this one from the Charleston Post and Courier. These aren’t advocacy pieces—the local resident profiled by the Post and Courier actually opposes Medicaid expansion—but they offer a much fuller picture of healthcare inequalities, and how little most politicians know about what it’s like to be poor in America.
Again, though, they’re the exception. More common is the sort of coverage that accompanied the debate over expansion in Virginia earlier this month: lots of editorials, reports on rallies and the political fight, and maybe some anecdotal leads about patient experiences that give way to typical stories. The coverage is responsible but formulaic. It’s also a little bloodless. Compare those Texas links above to this quote Khazan got from a medical student at a free clinic in Galveston, where Mark, the cancer patient, lives: “You are called upon to sit and listen to somebody’s story, and you look in their mouth and their teeth are messed up, and you listen to their heart and there’s a murmur, and you’re telling them there’s a treatment for this, but the state has decided they should not be able to get that treatment.”
This pattern is especially striking because the dominant press narrative on healthcare since last fall has focused intensely on the personal experiences of a different set of people—those who have been shopping for policies on the new insurance exchanges. Reporters have rushed to tell the stories of Americans who were thwarted by non-functioning websites, had their policies cancelled, and had to change providers. These victims had tales—sometimes exaggerated—that went viral and dominated the news cycle, but they can still get insurance. Those in the Medicaid gap can’t; their tales rarely make the local paper. (As for people who are able to sign up for Medicaid, they must navigate a bureaucracy that often rivals any Healthcare.gov headache. But for the most part, forget about media coverage of that.)