Medicaid Expansion

Back in 2018, I was all over the trend of deep red states putting ACA Medicaid expansion on the ballot after getting fed up with years of their elected leaders refusing to do so. Idaho, Utah and Nebraska voters all did exactly that, passing it by solid margins. Unfortunately, state Republicans got in the way (or at least tried to) in all three states, adding hurdles, barriers and caveats which have either delayed or partly weakened them.

Nonetheless, Utah and Idaho have both implemented Medicaid expansion to low-income residents (and thank God, given the current ongoing COVID-19 pandemic), while as far as I can tell, Nebraska is scheduled to launch their expansion program (called "Heritage Health") starting this October.

I wrote about this several times last year, but I'm a bit embarrassed to say that I haven't revisited the status of Oklahoma's Medicaid expansion ballot proposal since November:

In Red State Oklahoma, Medicaid Expansion Nears 2020 Ballot

A campaign in Oklahoma to expand Medicaid via the ballot box far eclipsed the necessary number of signatures needed to put the measure before voters next November 2020, supporters said Thursday.

The submission of 313,000 signatures to put a constitutional amendment on next year’s general election ballot shattered the required 178,000 needed by the Oklahoma Secretary of State’s office, organizers said. Media reports in Oklahoma said supporters of Medicaid expansion broke a state record when it comes to signatures needed for a statewide ballot initiative.

Last evening, over three years after I posted my "If I Ran the Zoo" wish list of recommended improvements for the ACA, the U.S. House of Representatives finally passed H.R. 1425, the Patient Protection & Affordable Care Enhancement Act (#AHEA), which I simply dub "ACA 2.0":

House Democrats on Monday passed a bill that would bolster the Affordable Care Act by hiking premium subsidies and incentivizing states to expand Medicaid.

I wrote up a detailed, step-by-step explainer of all 30 provisions of the ACEA last week, and couldn't be happier to see it finally pass through at least one Congressional body.

Unfortunately...

OK, this surprised me a bit: #HR1425, the Patient Protection & Affordable Care Enhancement Act, has already received a 10-year budgetary impact score from the Congressional Budget Office. I don't think this is a formal score--the whole thing is only five pages and includes minimal text accompanying it, so it might be just a "draft" score or something. I presume that if Mitch McConnell were to shock everyone and actually give it a vote in the Senate (which won't happen), there would likely have to be a second, more elaborate scoring process done by the CBO first. Then again, perhaps not.

Anyway, in a nutshell, the CBO report on the House version of H.R. 1425 comes to the following conclusions regarding the budget impact and other, related results of the bill being implemented nationally. Keep in mind that this assumes that the bill became law and was implemented starting in 2021; the score includes the 10 year period from 2021 - 2030:

TITLE I: Lowering Healthcare Costs & Protecting People w/Pre-Existing Conditions:

OK, I don't know if I "scooped" everyone with my H.R. 1425 explainer yesterday or what, but the House Energy & Commerce Committee just now sent out an official press release announcing the bill, along with a one-page summary, more detailed explainer and the link to the text itself. It's kind of interesting to see what language they use and which sections they emphasize, espeically as compared & contrasted with my own write-up:

Health Committee Chairs Unveil Legislative Package to Make Health Care & Prescription Drugs More Affordable

Legislation Also Expands Access to Health Care, Protects People with Pre-Existing Conditions & Reverses Administration’s Ongoing Sabotage of the ACA

Back in early March (a lifetime ago given the events of the past few months), House Democrats were on the verge of finally voting on a suite of important ACA protections, repairs and improvements which I've long dubbed "ACA 2.0" (the actual title of the first version of the "upgrade suite" bill was ridiculous when it was first introduced in 2018, and the slightly modified version re-introduced in 2019 was somehow even worse, no matter how good the bill itself was).

The game plan was to hold a full floor vote in the House on H.R. 1884 (or possibly a slightly different variant) the week of March 23rd, 2020 to coincide with the 10th Anniversary of the Affordable Care Act itself. This would have made perfect sense both symbolically as well as policywise, as the ACA desperately needs a major upgrade (and it would've needed one even without years of Trump/GOP sabotage, I should note).

Regular readers may have noticed that after a 3-4 month hiatus, I've recently started writing several stories touting "ACA 2.0"-type bills again over the past week or so.

First, last Tuesday, I dusted off my "How much would H.R. 1868 lower YOUR premiums?" series, in which I look at real-world examples of the impact of killing the ACA subsidy cliff (i.e. the 400% FPL income eligibility threshold) and beefing up the underlying subsidy formula in specific parts of the country. Then, on Monday, I wrote an updated explainer of a newer bill, H.R. 6545, an Age-Based subsidy enhancer, which I'm touting as a perfect companion bill to go alongside H.R. 1868.

One by one, the dozen or so states which had either already implemented work requirement programs for Medicaid expansion enrollees or which were planning on doing so have either "delayed" or dropped those requirements entirely, either by force due to a federal judge ruling against them, or "voluntarily" due to them seeing the writing on the wall and realizing that a federal judge was going to rule against them in the near future.

Every state except one, that is: Utah.

Utah passed ACA Medicaid expansion solidly back in 2018...and they passed a "clean" version, which was supposed to mean anyone earning up to 138% of the Federal Poverty Line would be eligible, and the program wouldn't have any barriers or hurdles like work requirements and so forth.

Late last night, the U.S. Senate finally voted to approve a massive $2 TRILLION bailout/recovery bill in response to the Coronavirus pandemic. After a lot of haggling and drama, the final bill ended up passing unanimously, 96 - 0 (four Republican Senators weren't able to vote at all...due to being in self-isolation because of Coronavirus). It's expected to be quickly passed by unanimous consent in the House today and will presumably be signed by Donald Trump before nightfall.

And like that, the largest emergency economic influx bill in history is done.

There's a lot of explainers and thinkpieces being written about the bill as a whole...which elements are good, which are bad, which are flat-out offensive (especially the ~$500 billion in corporate giveaways, which still ended up in the final bill although they supposedly have some sort of oversight over which companies receive them and under what conditions), but my focus is of course on the healthcare aspects, and especially what it means for enrollment in ACA exchange plans and Medicaid via ACA expansion.

For nearly three years now, the Trump Administration and Republican politicians across dozens of states have been claiming that expanding Medicaid to "able-bodied adults" encourages them to be lazy couch potatoes, lying around on their butts just soaking up all that sweet, sweet free healthcare coverage. That's the main excuse they've used to tack on draconian work requirements for Medicaid expansion enrollees: Supposedly doing so goads them into getting off their rumps, pulling themselves up by their bootstraps and becoming a Productive Member of Society, etc etc.

Of course, the reality is that most Medicaid expansion enrollees already work, and of those who don't most are already either in school, caring for a child or a medically frail relative, etc etc...meaning that work requirements impose a mountain of burdensome paperwork and reporting requirements in order to "catch" a tiny handful of people who supposedly match the "lazy bum" stereotype...but instead end up kicking thousands of people who are working/in school/etc. off of their coverage because they aren't able to keep up with the reporting requirements.

via KIVI Boise:

The number of Idaho residents who have signed up for Medicaid under the state’s voter-approved expanded coverage has passed 60,000.

The Idaho Department of Health and Welfare posted updated numbers Thursday. The agency estimates 91,000 residents meet requirements.

Coverage started January 1, but enrollment is year-round. Those who sign up for Medicaid will be covered for doctor visits that occurred earlier in the same month.

Voters authorized Medicaid expansion in 2018 with an initiative that passed with 61% of the vote after years of inaction by state lawmakers. In 2019, lawmakers added restrictions requiring five waivers from the U.S. Department of Health and Human Services.

Waivers are required when states want to deviate from Medicaid rules. Federal officials have yet to approve any of Idaho’s requested waivers.

If the anticipated 91,000 people do eventually sign up, it would cost Idaho about $400 million, with the federal government paying 90%.

Even as I'm typing this, Democratic (!) Kansas Governor Laura Kelly and Republican legislative leaders are holding a press conference to announce an agreement to finally expand Medicaid under the ACA:

TOPEKA, Kan. (KWCH) Gov. Laura Kelly and Republican leadership announce an agreement on Medicaid expansion in Kansas.

During a press conference on Thursday, the governor said the program would be funded by the hospital administrative fee. At this time, it's unknown if that fee would be passed on to patients.

Kelly said the hospitals have endorsed the program.

Kansas Senate GOP Majority Leader Jim Denning said the bill would be pre-filed on Thursday with 22 co-sponsors.

If passed in the Kansas Senate and House, the full expansion would go into effect no later than Jan. 1.

(Obviously that's January 1st of 2021 at this point, of course)

Here's some live tweeting of the event by a Kansas-based political reporter:

This Just In via email...

Your Health Idaho enrolls 89,000 Idahoans for 2020 health insurance coverage

  • Idaho exchange sees increase in new customers as overall enrollments decline amid Medicaid expansion

BOISE, Idaho – More than 89,000 Idahoans signed up for 2020 health insurance coverage through the state insurance exchange, Your Health Idaho, during open enrollment which ended Dec. 16, 2019.

Enrollments are down approximately 14,000 from the same time last year. This decline is largely due to Medicaid expansion and was expected by the exchange. Your Health Idaho originally estimated that around 18,000 individuals would move from the exchange to Medicaid under the newly expanded program. 

A brief recap of ACA Medicaid expansion in the great state of Utah:

  • November 2018: Utah voters pass Proposition 3, a "clean" Medicaid expansion ballot initiative, by a solid margin, 53-47. "Clean" expansion means just that: The program would be expanded to every legally documented Utah resident earning up to 138% of the Federal Poverty level, without requiring additional barriers like work requirements, etc.
  • February 2019: The Utah state legislature, blatantly defying the clear will of the people, votes to effectively ignore Prop 3 by replacing it with Senate Bill 96, which would only partially expand Medicaid to those earning just 100% FPL (around 50,000 fewer low-income residents) while also tacking on work requirements to boot.
  • Adding insult to injury, while you might think this would at least save the state a few bucks (under ACA Medicaid expansion, the federal government pays 90% of the bill for the expanded population while the state has to pay the other 10%), this would actually cost the state around $50 million more, because the partial expansion, if approved by the federal government, would mean the state would instead pay the 32% portion they already pay for other Medicaid populations. The state put in a separate waiver request asking for the feds to agree to the 90% match rate anyway.

Elections matter.

True to his word, newly-inaugurated Democratic Kentucky Governor Andy Beshear has indeed eliminated the state's controversial and much-litigated Medicaid work requirement provision for the 400,000 state residents who are on the low-income healthcare program thanks to the Affordable Care Act:

Former Republican Gov. Matt Bevin’s controversial plan to impose work requirements and monthly premiums for many Kentucky Medicaid recipients is no more, Democratic Gov. Andy Beshear announced Monday.

(Monday = Last Monday; this is from a week ago)

In one of his first major moves as the 63rd governor of Kentucky, Beshear signed an executive order Monday rescinding Bevin’s Kentucky HEALTH plan, which sought to impose strict work requirements for able-bodied, working-age adults. It would have ended health coverage for an estimated 95,000 Kentuckians.

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