Tomorrow, the big news for the Affordable Care Act will be the opening of the state-level insurance exchanges. But the other major part of the law, Medicaid expansion, proceeds apace. Republican governors in many states have simply rejected Medicaid increases, presumably on the grounds that providing poor people with health insurance is a nefarious communist plot. However, some GOP-dominated states like Michigan or divided-control states like Arkansas are working with the Department of Health and Human Services to develop alternative routes for expanding Medicaid coverage to the working poor. The challenge for the Obama administration (and progressive activists) is to determine which plans stay true to the spirit of the ACA and which ones may dangerously undermine it.
Obviously, the biggest goal is to increase coverage, but we also need to be mindful of the
various strings that conservative governors and legislators might attach to the
modified plans seeking waivers from the Department of HHS.
Medicaid expansion was originally supposed to automatically
apply to all states, but the Supreme Court’s 2012 ruling on the Affordable Care
Act made it optional. Not surprisingly, 14 states with unified Democratic
control immediately signed up for the expansion; the opportunity to provide
universal health insurance to residents under 138 percent of the poverty line
fulfilled a longstanding progressive dream – all made possible by the federal
government picking up 90 percent of the long-term costs.
Of 24 states under complete GOP control, only two took the
traditional expansion (North Dakota and Arizona) while 17 rejected it entirely.
Six of the 12 states with divided control governments agreed to the standard
expansion, while three have passed for now. (Here's a handy map with the state decisions)
That leaves six states under GOP control
(Pennsylvania, Ohio, Michigan, Indiana, Tennessee and Florida) and three states
under with split control (Arkansas, Iowa and New Hampshire) that are either still actively considering
the expansion or have proposed a non-traditional style of expanding Medicaid
more agreeable to Republican majorities.
And that’s where things have gotten interesting. Follow me
below the break for details.
The story starts in Arkansas last winter, where Democratic
Gov. Mike Beebe favored expansion, but faced a newly elected hostile GOP
legislature, which needed to approve any expansion plans by a ¾ vote. Republican leaders told Beebe they would only
consider doing an expansion if it were “market-based.” In response, Beebe and
his staff proposed using the federal Medicaid dollars to let newly-eligible
Medicaid recipients purchase commercial plans on Arkansas’ insurance exchange.
Beebe got the votes for the compromise (SSH! don’t tell Ted Cruz or the Club
for Growth), and last Friday the Department of Health and Human Services approved
Arkansas’ waiver.
Iowa soon followed suit by approving a similar plan and is
waiting for a final ruling on its waiver application from HHS, which should
come in the next several weeks.
This analysis from the Kaiser Foundation compares
Iowa’s and Arkansas’ expansion plans. In both states, the newly eligible
Medicaid population would be allowed to choose one of several "high-value" Silver-level exchange plans. Arkansas’ plan would mandate some cost-sharing through
co-pays for medical services for those above 50 percent of the poverty line,
while Iowa’s would mandate paying a premium of $20 a month – which could be
waived if the recipient met several health-improvement activities. Both plans
would cap medical expenses (including premiums) at 5 percent of income.
Last month, Michigan passed its own
expansion bill with a different wrinkle. New enrollees in
Medicaid would have to enroll in managed-care plans run by a private
contractor selected by the state. Most
states already have some of their Medicaid populations in this model, though opinions differ on whether it actually saves money or improves services. Michigan follows the lead of Florida Governor Rick Scott’s
attempt to expand Medicaid in Florida under a managed-care model. Florida’s
legislature balked last summer and the plan is on life support (unlike the roughly 950,000
Florida citizens eligible for the expansion, who currently get no support.)
Other features of Michigan’s plan include mandatory health
savings accounts, to which those covered must contribute at least 2 percent of
their income to help pay for co-pays. Cost
sharing would be capped at 5 percent, increasing to 7 percent after four years
in the program. Those enrolled in Medicaid after four years can escape the
higher cost savings requirements by purchasing insurance on the exchanges with state
funds.
Ohio is also looking seriously at a
similar plan, while Missouri, Alaska, South Dakota and Kansas(!) have at least started publicly
discussing a premium-support model for Medicaid. Pennsylvania Gov. Tom Corbett
has come out grudgingly in favor of an Arkansas-style model.
For progressives, these plans hold certain promise and some
potential pitfalls. Most obviously, these plans get the working poor and
near-poor health insurance coverage – 470,000 in Michigan, 250,000 in Arkansas and 106,000 in Iowa. This coverage is real coverage. By the terms of the ACA, plans offered on the marketplace
need accept all applicants regardless of pre-existing conditions, include a
basket of standard services and provide free preventative care. Covering these individuals would easily save several hundred, perhaps several thousand lives in a year.
If the choice for liberals are these hybrid premium support
or managed-care plans, or nothing, the choice is clear – that showed up in the
unanimous Democratic legislative support in Arkansas, Iowa and Michigan, as
well as left-wing interest groups that enthusiastically backed the measure.
(Labor pushed hard in Michigan to get votes, especially the nurses unions)
But there are trade-offs for compromising to achieve this
long-cherished goal. In particular, the emphasis the plans put on cost sharing
for the working poor is disturbing. Though all three plans place hard caps as a
percentage of income on cost sharing from premiums, co-pays and co-insurance,
the push to make sure that poor people have “skin in the game” for their health
care seems at best misplaced. The emphasis on wellness programs and goals seems
a bit intrusive as well (though it’s a good thing to get the working poor
access to things like smoking cessation programs that are easily in reach of the
financially well-off). It’s a stretch to compare it to mandatory drug testing
for welfare recipients, but there does seem to be the whiff of a paternalistic stigma
about poor people’s bad health habits being responsible for their poverty.
Finally, there is the question of having private contractors
getting more influence in running greatly expanded managed care programs, some
of which have quite a checkered history. One of the major progressive
accomplishments of the ACA was that it increased the breadth of government
insurance programs like Medicaid, limited corporate welfare for companies
selling Medicare advantage plans and greatly tightened regulations on
commercial insurers if they wanted to be able to take part in the exchanges. Allowing
too great of an expansion of managed care and premium support for the working
poor may give conservatives the ability to erode the strength of Medicaid and even
Medicare over time.
HHS Secretary Kathleen Sibelius and her staff have their
hands full as they try to balance all these issues against the primary goal of
better coverage as they consider waivers.
Ultimately, remember that elections have consequences. If
you elect competent people who favor good public policy, you tend to get good
public policy – just look at the 14 Democratic controlled states that quickly
accepted the Medicaid expansion. (Now, if only we could get them to think
productively about public pensions and education)
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