Days before House Republicans corralled their rowdy caucus into voting for the American Health Care Act (AHCA), late-night host Jimmy Kimmel opened his show with a rare emotional plea. Choking back tears, Kimmel told audiences that his baby son had just undergone open-heart surgery for a genetic condition. Under the Republican proposal, pre-existing conditions like congenital heart disease could prevent families like his from finding affordable health care insurance. "No parent should ever have to decide if they can afford to save their child's life," Kimmel concluded. "It just shouldn't happen. Not here." (1)

Kimmel's footage added to a wildfire of opposition to the AHCA. And the House GOP's plan is indeed dastardly. Individuals with pre-existing conditions who are fired or otherwise temporarily lose insurance will likely be forced to choose between skyrocketing premiums or going without vital care—and either option can sink a middle-class home into poverty. If the Senate passes a health care reform bill that resembles the House version, the Kaiser Family Foundation estimates that 52 million Americans could be stranded without coverage. (2)

And so it makes sense that the attack on individuals with pre-existing conditions has drummed up the most vocal opposition to the AHCA. After all, cancer, heart defects, and brain tumors don't discriminate. Anyone could become subject to what insurance companies consider a "pre-existing condition," regardless of race, class, or savings account balance.

But the focus on pre-existing conditions overlooks the fact that the AHCA does far, far more to devastate health care access. It is especially threatening for low-income and unemployed Americans living in rural areas—a disproportionate number of whom are Black and Latinx, a disproportionate number of whom live in the South.

Most significantly, the AHCA would cut back Medicaid funding by 25 percent over the next 10 years. (3) Established in 1965 to provide healthcare for the poor, Medicaid has proven to be one of the most successful welfare programs in the country's history. It has kept healthcare costs lower per beneficiary, and it keeps those costs growing more slowly than private insurance markets. (4) Patients who receive Medicaid are less likely to put off medical treatment due to financial constraints, and they tend to enjoy better care. (5) Moreover, the program offers crucial support for hospitals and medical services in low-income areas. It has also proven instrumental in covering people with disabilities, and in responding to the current opioid crisis.

With the 2010 passage of the Affordable Care Act (ACA), the Obama administration expanded Medicaid. When the Supreme Court ruled that individual states could opt out of the expansion, 19 states decided not to expand Medicaid for their low-income residents. Nine of those states are in the South. Even as they face pressure from their constituents, conservative legislators in places like North Carolina and Virginia refuse to consider expansion, leaving an estimated 500,000 and 400,000 people, respectively, without access to health care coverage. All told, some 5 million Southerners are estimated to be without health insurance that would have been covered. (6)

Now, in seeking to repeal and replace the ACA, House Republicans have passed a bill that will entrench and expand those gaps in coverage. In addition to significantly defunding Medicaid, the House bill could turn much of the program into block grants. This will limit its ability to keep up with rising costs, undoing one of the features that made Medicaid so successful even prior to the Obama administration's expansion.

This structural fetter will eventually force states to cover fewer people or offer poorer care. (7) People will die. People will die. Overwhelmingly, those people will be the individuals and families who have historically benefitted most from Medicaid: poor people, precariously employed people, the disabled, people in rural or post-industrial areas. Southerners, especially Southerners of color.

Yet so far, most of the pushback against the AHCA has fixated on how it and other Republican proposals would hurt middle- and upper-class Americans with pre-existing conditions—families like Jimmy Kimmel's. If we can measure social value by looking at which lives the government works to sustain and which it neglects, we can also measure it by examining which lives the opposition holds up as worthy of protection—and which it ignores. It is time that progressives, particularly those in the South, defend the threatened programs that benefit the less well-off among us. It's time to stand up for Medicaid.

No longer should we settle for two-tier entitlement programs that reward individuals with means while neglecting those who most need help. Medicaid is worth fighting for, because lives depend on the program as it currently exists. And in it, we might find a model for a universal coverage program that doesn't make health care dependent on the ever more uncertain stamp of gainful employment. Our health shouldn't depend on our work. It's the other way around—our ability to work depends on our good health.


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