Medicaid Expansion

Montana didn't expand Medicaid under the Affordable Care Act until January 2016, and when they did so, the legislation was written with an automatic sunset date of June 30, 2019 unless it's expanded beyond that. Unfortunately, the ballot proposal to make Medicaid expansion permanent failed last November, which put the issue back in the hands of state lawmakers.

The good news is that the Montana state legislature did indeed finally vote to extend the program, which covers around 96,000 people, this week. The bad news is...well:

The bill to continue Medicaid expansion in Montana passed out of the state Senate Tuesday after teetering on the edge of a deadline for end of session negations.

A week or so ago there was an important ruling by a federal judge which shot down Medicaid expansion work requirements in two states (Arkansas and Kentucky) while also having a ripple effect in two more (Idaho and Iowa):

The [Idaho] Senate Health and Welfare Committee voted 7-2 to hold in committee a House bill that would create a work requirement for Medicaid expansion beneficiaries — after lawmakers found out during the hearing that a federal judge had just struck down Medicaid work requirements in Kentucky and Arkansas.

Meanwhile, a Senate bill that would create a voluntary job training requirement for Medicaid expansion beneficiaries is still in that chamber’s amending order and could come up soon. The Medicaid budget for 2019-2020 is still being held in the full House. And Gov. Brad Little has said he won’t let lawmakers adjourn for the year until Medicaid expansion and funding is resolved.

Governor Mills Announces Federal Approval of Medicaid Expansion

Governor Janet Mills announced today that the U.S. Centers for Medicare and Medicaid Services (CMS) has approved Maine’s State Plan Amendments to expand Medicaid (MaineCare) under the Affordable Care Act. CMS notified the Maine Department of Health and Human Services (DHHS) of the approval today.

CMS approved the state’s plan retroactive to July 2, 2018, which was the date indicated in the 2017 ballot initiative supported by nearly 60 percent of Maine voters. MaineCare expansion is projected to provide coverage to approximately 70,000 people throughout the state. With today’s approval, the federal government will finance more than $800 million in estimated costs for those who enroll under expansion from July 2, 2018 through state fiscal year 2021. Maine is among 36 states plus the District of Columbia that have expanded Medicaid.

From February:

The full expansion initiative passed last fall, of course, is supposed to cover Utah residents earning up to 138% of the poverty line, or around 150,000 people...without any work requirements.

The bill barreling through the Utah Legislature was “an effort to override the will of the people,” said Matthew Slonaker, the executive director of the Utah Health Policy Project, a nonprofit group that supported the full expansion of Medicaid.

Utah lawmakers, worried that the sales tax increase might not fully cover the costs, are rushing through a bill that would limit the expansion of Medicaid to people with incomes less than or equal to the poverty level, about $12,140 for an individual.

State officials say that the bill, which is estimated to cover 90,000 people, could be on the desk of Gov. Gary R. Herbert, a Republican, in a week or two.

Nearly two years ago, normally deep red Kansas came within a whisker of pulling off the impossible:

Kansas House fails to override Brownback Medicaid expansion veto

The effort to expand Medicaid in Kansas fell apart Monday as the House failed to override Gov. Sam Brownback’s veto of a bill that would have expanded the health care program to thousands of low-income people in the state.

The 81-44 vote, three shy of the 84 needed to overcome the governor’s opposition, effectively ends the Medicaid expansion push in Kansas after it successfully passed both chambers with bipartisan support earlier this year.

That was then. This is now. Kansas now has a Democratic governor who supports Medicaid expansion, and yesterday this happened (via Jim McLean of the Kansas News Service):

Last year, Republican Governor of Kentucky Matt Bevin, who had campaigned heavily on a promise to repeal ACA Medicaid expansion altogether, partly changed his tune once he actually took office. Instead of kicking all 450,000 low-income Kentucky residents off the program completely, he first imposed an absurdly insulting and cumbersome "frequent flyer"-style program:

Kentucky is moving closer to an overhaul of the state's Medicaid program Bevin has said is aimed at controlling costs and encouraging more personal responsibility in consumers, changes that include elimination of basic dental and vision benefits for most "able-bodied" adults who instead would have to earn them through a "rewards" program.

..."It is expensive to go to a dentist," he said. "These changes are just ludicrous."

When I last checked in to see how Virginia's newly-enacted ACA Medicaid expansion program was doing, they had already enrolled around half of the 400,000 estimated residents eligible to do so statewide.

Last fall, I estimated that perhaps 85,000 of those newly eligible to enroll in Medicaid would actually be "cannibalized" from the existing ACA exchange enrollee population...and sure enough, when the 2019 Open Enrollment numbers were posted, exhange enrollment in Virginia was down by 72,000 people, putting them dead last nationally in terms of year over year performance (down 18% from 2018).

Unfortunately, without an income demographic breakout, there's no way of being certain how much of that dropoff was due to Medicaid expansion as opposed to middle-income enrollees simply choosing to drop their coverage.

Today, however, Virginia state delegate Danica Roem posted the following update, which includes a link to a very nifty interactive graphic Medicaid expansion dashboard:

(sigh) via Joan Alker of the Georgetown University Health Policy Institute:

Last week, the state of Arkansas released its latest round of data on implementation of its Medicaid work reporting requirement – the first in the country to be implemented. As readers of SayAhhh! know, over 18,000 lost coverage in 2018 as a result of not complying with the new reporting rules. And the policy is clearly failing to achieve its purported goal – incentivizing work – with less than 1% of those subject to the new policy newly reporting work or community engagement activities.

via Greg Bluestein & Ariel Hart of the Atlanta Journal-Constitution:

Gov. Brian Kemp will ask the Georgia Legislature and the federal government for flexibility to improve access to government-funded health insurance for the state’s poor and middle class.

His administration told The Atlanta Journal-Constitution on Thursday that it will back a measure that seeks two separate federal “waivers” to Medicaid and the Affordable Care Act to tailor new programs to Georgia’s needs.

This sounds potentially promising, but...

...The ACA waiver, which he outlined on the campaign trail, aims to stop premiums on the health insurance exchange market from rising so fast. A second push, which emerged after his election, would raise the possibility of a partial expansion of Medicaid to some of Georgia’s poorest residents.

Hmmmm...

I wrote about this a week ago...

The full expansion initiative passed last fall, of course, is supposed to cover Utah residents earning up to 138% of the poverty line, or around 150,000 people...without any work requirements.

The bill barreling through the Utah Legislature was “an effort to override the will of the people,” said Matthew Slonaker, the executive director of the Utah Health Policy Project, a nonprofit group that supported the full expansion of Medicaid.

Utah lawmakers, worried that the sales tax increase might not fully cover the costs, are rushing through a bill that would limit the expansion of Medicaid to people with incomes less than or equal to the poverty level, about $12,140 for an individual.

State officials say that the bill, which is estimated to cover 90,000 people, could be on the desk of Gov. Gary R. Herbert, a Republican, in a week or two.

 

Light posting for the next two weeks as I'm dealing with my kid's upcoming bar mitzvah and some other personal stuff, but this one literally hits home.

You may recall that last spring, Republicans in the Michigan legislature attempted to push through a bill to change the state's current ACA Medicaid expansion program (which is close to "vanilla" Medicaid with a few minor tweaks) by tacking on pointless, ineffective and (in an earlier draft) blatantly racist work requirement provisions:

White, Rural GOP Counties Get Exempted from Medicaid Legislation

Republicans in the legislature are working to change Medicaid in Michigan, but only for certain people, as they have tailored the language of pending legislation to exempt some of their constituents from being affected.

I'm rather late to the game on this issue, but it looks like the story is already making major headlines elsewhere so I don't feel too bad; via Robert Pear of the NY Times:

In Utah and Idaho, G.O.P. Looks to Curb Medicaid Expansions That Voters Approved

The voters of Utah and Idaho, two deeply Republican states, defied the will of their political leaders in November and voted to expand Medicaid under the Affordable Care Act. Now those leaders are striking back, moving to roll back the expansions — with encouragement, they say, from the Trump administration.

Utah’s ballot measure, approved with support from 53 percent of voters, would expand Medicaid to cover people with incomes up to 138 percent of the poverty level — up to about $16,750 a year for an individual — and pay the state’s share with a small increase of the sales tax. Under the ballot initiative, 150,000 people are expected to gain coverage, starting April 1.

Back in April 2017, I compiled a 20-itme "ACA 2.0 wish list" which I titled "If I Ran the Zoo", which gained some amount of attention from the healthcare policy wonk community. To be clear, I wasn't the first one to come up with most of these ideas; it was mainly just pulling together a bunch of proposals to protect, repair and strengthen the ACA from various sources into a single, comprehensive collection.

Since then, several bills have been introduced by Democrats in either the House or the Senate which addressed one or more of these recommendations, and last spring there were two bills (one in the House, one in the Senate) which tackled over a half-dozen of them in a package deal. None of these bills have gone anywhere since then, of course; with the Dems having retaken the House, it's a lot more viable that one or more will do so this year, although getting any of them through the Senate is obviously a much tougher climb.

However, some of the items on the list haven't even made it that far, including #5 on my list:

*(Yes, that's sarcasm...it's been anything BUT "just like that" in Maine...)

Openly racist and mini-Trump GOP Maine Governor Paul LePage spent the better part of the past eight years blocking the expansion of Medicaid under the Affordable Care Act. First, he vetoed the Medicaid expansion bills passed by the state legislature a whopping seven times. Then, when Maine voters finally had enough and successfully passed a statewide ballot initiative to force the issue, LePage spent another full year continuing to fight against actually implementing the expansion provision via legal challenges and flat-out violation of court orders.

This happened while I was out of town, but it's welcome news nonetheless...

Governor Northam Announces Medicaid Expansion Hits Milestone with More Than 200,000 Enrolled
Virginians can apply at any time of the year

RICHMOND—Governor Ralph Northam announced Friday that more than 200,000 Virginia adults are now enrolled and will have health coverage starting January 1. The achievement marks a major milestone in the Medicaid expansion initiative approved last summer.

“This bipartisan initiative has empowered men and women across the Commonwealth to take an active role in improving their health,” said Governor Northam. “The historic response from our citizens demonstrates the need for access to health coverage that will benefit our families, our communities and Virginia’s economy. I encourage uninsured individuals to learn more about this new health coverage opportunity and to apply today.”

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