The Six States That Can’t Decide on Medicaid Expansion

A small handful of states remain in negotiations with themselves and the federal government over if and how to expand Medicaid under the Affordable Care Act.

National Journal
Sophie Novack
See more stories about...
Sophie Novack
March 19, 2014, 8:08 a.m.

For the fi­nal six hol­d­outs, the de­cision of wheth­er to ex­pand Medi­caid un­der the Af­ford­able Care Act has be­come a del­ic­ate tug-of-war between state of­fi­cials and the fed­er­al gov­ern­ment.

The Af­ford­able Care Act ex­pands Medi­caid cov­er­age to all adults be­low 138 per­cent of the fed­er­al poverty level. Un­der the law, the fed­er­al gov­ern­ment will cov­er 100 per­cent of the cost for the first three years — from 2014 to 2016. The fed­er­al con­tri­bu­tion then gradu­ally de­clines to 90 per­cent, where it will re­main.

However, the Su­preme Court ruled in 2012 that the de­cision to ex­pand must be left up to the states. While the Obama ad­min­is­tra­tion as­sumed that states would still jump at the fed­er­al fund­ing, this turned out not to be the case.

The “road to yes,” as Matt Salo — ex­ec­ut­ive dir­ect­or of the Na­tion­al As­so­ci­ation of Medi­caid Dir­ect­ors — calls the de­cision, is com­plex and unique to each state. In those still de­cid­ing, there are a num­ber of factors — polit­ic­al, fin­an­cial, ideo­lo­gic­al — to con­sider, and vari­ous ways the pro­gram can be im­ple­men­ted.

“This is not just a ques­tion of what does the state want,” Salo says. “In this case it’s a com­bin­a­tion of the gov­ernor and le­gis­lature, which can be of the same party or dif­fer­ent parties, and can have subtly or rad­ic­ally dif­fer­ent ideas of what they want done.”

“I do think that the vast ma­jor­ity of states would like to get to ‘yes’; it’s just yes for them may look dif­fer­ent from what the ad­min­is­tra­tion is cur­rently will­ing to do,” he con­tin­ued. “A lot of states are sit­ting on the side­lines at the mo­ment and try­ing see if they can get a bet­ter sense of how far the ad­min­is­tra­tion is will­ing to come.”

The White House did not set any dead­line for a fi­nal de­cision on Medi­caid ex­pan­sion, and states may change at any time.

Cur­rently, 25 states and the Dis­trict of Columbia have op­ted in­to Medi­caid ex­pan­sion, while 19 have op­ted out. That leaves six that have not yet de­cided.

Here is what’s go­ing on in those limbo states:

New Hamp­shire

New Hamp­shire is on the brink of ex­pand­ing Medi­caid to ap­prox­im­ately 50,000 low-in­come res­id­ents. The Re­pub­lic­an-con­trolled Sen­ate voted 18-5 earli­er this month to pass the state’s ver­sion of ex­pan­sion un­der the ACA. The Demo­crat­ic-con­trolled House is ex­pec­ted to pass the bill in the next couple of weeks, and Demo­crat­ic Gov. Mag­gie Has­san has said she sup­ports it.

The bi­par­tis­an New Hamp­shire plan calls for put­ting all newly eli­gible adults in­to a premi­um as­sist­ance mod­el sim­il­ar to the ap­proach in Arkan­sas, which will use fed­er­al funds to buy private in­sur­ance plans on the ex­changes.

However, be­cause the pro­cess for im­ple­ment­ing the “private op­tion” can be lengthy — with draft­ing the waiver and put­ting it up for pub­lic com­ment — the state will move for­ward with ex­pan­ded cov­er­age in the mean­time, ac­cord­ing to De­borah Ba­chrach, part­ner at Man­att Health Solu­tions, which is as­sist­ing with Medi­caid ex­pan­sion in New Hamp­shire. Be­gin­ning Ju­ly 1, newly eli­gible adults will be­gin re­ceiv­ing cov­er­age through the ex­ist­ing Medi­caid man­aged care plan, and will later be transitioned onto the private mar­ket.

“This drives home that this is time sens­it­ive; that state lead­er­ship wants to start cov­er­age, bring in fed­er­al dol­lars, and have the fed­er­al match­ing rate,” Ba­chrach says.

The state an­ti­cip­ates that some, if not all, of the Medi­caid man­aged care plans will be­come plans on the private mar­ket, which could have a sig­ni­fic­ant im­pact on com­pet­i­tion in the New Hamp­shire ex­change, as there is cur­rently only one in­surer par­ti­cip­at­ing.

Vir­gin­ia

Vir­gin­ia is at an im­passe on Medi­caid ex­pan­sion, with the gov­ernor strongly in fa­vor and the Re­pub­lic­an-led House fer­vently op­posed.

Demo­crat­ic Gov. Terry McAul­iffe, elec­ted in Novem­ber, cam­paigned on the is­sue of Medi­caid ex­pan­sion and has made it his mis­sion to pass it in Vir­gin­ia. Yet while the state Sen­ate sup­ports the ex­pan­sion bill, the House is not budging. The polit­ic­al stan­doff con­tin­ues, as McAul­iffe travels the state to rally sup­port for the le­gis­la­tion ahead of the spe­cial ses­sion.

“The gov­ernor is re­l­at­ively new, and this de­bate has ex­is­ted in the Vir­gin­ia Le­gis­lature for years,” says Salo. “The gov­ernor said it’s his No. 1 pri­or­ity — the GOP prob­ably doesn’t want to hand him a vic­tory on his No. 1 pri­or­ity right away.”

The state’s Gen­er­al As­sembly ad­journed nearly two weeks ago without passing a budget or Medi­caid ex­pan­sion. The Le­gis­lature will re­turn for a spe­cial ses­sion at the end of this month, but neither side is show­ing signs of cav­ing. McAul­iffe has re­jec­ted calls from Re­pub­lic­an law­makers to sep­ar­ate Medi­caid ex­pan­sion from the two-year, $96 bil­lion state budget, and if the two sides can­not agree and pass a budget by the end of June, the state gov­ern­ment will shut down.

Ex­pan­sion would ex­tend cov­er­age to about 400,000 Vir­gin­ia res­id­ents.

Pennsylvania

If Re­pub­lic­an Gov. Tom Corbett’s pro­pos­al for Medi­caid ex­pan­sion is ap­proved, Pennsylvania will be the first state to tie work-re­lated cri­ter­ia to its Medi­caid pro­gram.

The plan is un­der re­view for ap­prov­al by the fed­er­al gov­ern­ment. Like a num­ber of oth­er states still in limbo, the pro­pos­al ac­cepts fed­er­al fund­ing to help low-in­come in­di­vidu­als pur­chase plans on the in­sur­ance ex­change. It would ex­pand Medi­caid to about 500,000 people.

However, Corbett’s pro­pos­al has at­trac­ted at­ten­tion for at­tempt­ing to es­tab­lish a work pro­gram with­in the health care pro­gram. It ori­gin­ally in­cluded a con­tro­ver­sial work re­quire­ment, which would man­date that those work­ing few­er than 20 hours a week par­ti­cip­ate in a job-train­ing pro­gram to be eli­gible for cov­er­age. The gov­ernor sent a let­ter to HHS earli­er this month, in­stead pro­pos­ing a vol­un­tary pi­lot pro­gram that would of­fer lower premi­ums and co-pays for con­sumers who par­ti­cip­ate.

The cur­rent hol­dup in Pennsylvania is more ideo­lo­gic­al than polit­ic­al, Salo ex­plains. “States are think­ing about things like how to cre­ate more per­son­al re­spons­ib­il­ity in gov­ern­ment be­ne­fits — wheth­er that’s look­ing to do drug test­ing for be­ne­fi­ciar­ies, or life­time lim­its on be­ne­fits, or re­quire be­ne­fi­ciar­ies to par­ti­cip­ate in a job search,” he says.

While HHS has ap­proved premi­um as­sist­ance mod­els in oth­er states like Arkan­sas and Iowa, these per­son­al-re­spons­ib­il­ity stip­u­la­tions enter new ground that fed­er­al of­fi­cials may not be will­ing tread.

“My sense is that the ad­min­is­tra­tion has no in­terest what­so­ever in en­ter­tain­ing any of those con­di­tions,” Salo con­tin­ues. “They don’t want to put that stigma on health care cov­er­age.”

Utah

Rep­res­ent­at­ives from Gov. Gary Her­bert’s of­fice are in D.C. dis­cuss­ing his Medi­caid ex­pan­sion plan with ad­min­is­tra­tion of­fi­cials this week. The state is cur­rently mov­ing for­ward with the Re­pub­lic­an gov­ernor’s plan, after pro­pos­als from the state House and Sen­ate failed to ad­vance be­fore the close of the le­gis­lat­ive ses­sion last week.

After re­frain­ing from opt­ing in for a long while, Her­bert made it clear in Janu­ary that he wanted to do something about Medi­caid ex­pan­sion, but he did not cla­ri­fy what ap­proach that might be un­til re­cently.

The gov­ernor’s Healthy Utah plan would ex­pand cov­er­age to adults be­low 138 per­cent of the fed­er­al poverty level, and use fed­er­al funds to buy private in­sur­ance for low-in­come adults. The plan would seek a fed­er­al block grant to cov­er the ap­prox­im­ately 111,000 Utahns un­der the in­come threshold. The three-year pi­lot pro­gram would ac­cept $258 mil­lion in fed­er­al funds in 2015.

“It’s more ro­bust [than the House and Sen­ate pro­pos­als],” says Kolbi Young, spokes­per­son for the Utah De­part­ment of Health. The House plan in­volved only state dol­lars with no new Medi­caid fund­ing, while the Sen­ate plan ac­cep­ted fed­er­al fund­ing but only ex­pan­ded cov­er­age to 100 per­cent of the poverty level.

Be­cause neither plan was passed, the gov­ernor is mov­ing ahead with his own.

The Healthy Utah plan in­cludes ele­ments of per­son­al re­spons­ib­il­ity as well. It in­volves some cost-shar­ing, and those mak­ing be­low $15,521 would pay $420 in an­nu­al premi­ums and med­ic­al costs. There is not an of­fi­cial work re­quire­ment in the pro­pos­al, but the motto as­so­ci­ated is “those who can work, do work.”

It is not yet known what the ad­min­is­tra­tion’s re­sponse will be. “The plan has not been presen­ted to CMS,” Young says. “That’s the next step.”

Mis­souri

Mis­souri has thus far been at a stand­still between Demo­crat­ic Gov. Jay Nix­on, who very much fa­vors ex­pan­sion, and a con­ser­vat­ive Re­pub­lic­an Le­gis­lature that is very much op­posed. However, that dy­nam­ic is be­gin­ning to show signs of shift­ing, and there is cur­rently le­gis­la­tion pending in the House to ex­pand the pro­gram.

Re­pub­lic­an Rep. Noel Tor­pey chaired an in­ter­im com­mit­tee ex­amin­ing Medi­caid ex­pan­sion last fall, ac­cord­ing to the Mis­souri De­part­ment of So­cial Ser­vices. From this came the bill be­fore the Le­gis­lature, which in­volves a kind of hy­brid between premi­um as­sist­ance and tra­di­tion­al Medi­caid ex­pan­sion.

Un­der the plan, in­di­vidu­als would be eli­gible for Medi­caid be­low 100 per­cent of the poverty level. Those between 100 and 138 per­cent would use premi­um as­sist­ance to pur­chase cov­er­age on the ex­change. About 300,000 Mis­souri­ans would be newly eli­gible for cov­er­age.

The bill also in­cludes a work-re­fer­ral re­quire­ment, al­though is is not a con­di­tion of eli­gib­il­ity, ac­cord­ing to Ba­chrach.

The next House hear­ing on the bill is sched­uled for March 25.

In­di­ana

In­di­ana has been held up on Medi­caid ex­pan­sion be­cause of a de­sire to con­tin­ue a pro­gram cur­rently in place in the state: the Healthy In­di­ana Plan.

HIP is a pi­lot Medi­caid pro­gram star­ted in 2008 that cov­ers low-in­come in­di­vidu­als whose in­comes are too high to qual­i­fy for Medi­caid but too low to buy in­sur­ance on the private mar­ket. The pro­gram is capped at about 45,000 in­di­vidu­als, and is modeled on health sav­ings ac­counts, re­quir­ing con­sumers to con­trib­ute a por­tion of their in­come so that they have a kind of buy-in for their cov­er­age. Medi­caid ex­pan­sion would ex­tend cov­er­age to about 400,000 in­di­vidu­als.

Re­pub­lic­an Gov. Mike Pence has re­mained com­mit­ted to main­tain­ing the HSA mod­el in Medi­caid ex­pan­sion con­sid­er­a­tions. In­di­ana has been gran­ted an year­long ex­ten­sion of HIP while of­fi­cials con­tin­ue to ex­plore op­tions for a full ex­pan­sion in the state.

“In­di­ana has been very very in­tent on us­ing [HIP] as the basis for Medi­caid ex­pan­sion—they want to be able to use this HSA ap­proach,” says Salo. “Un­til now, the ad­min­is­tra­tion has not looked on this ter­ribly fa­vor­ably; the ad­min­is­tra­tion is not at all in­tent on set­ting a pre­ced­ent of wide ex­pan­sion of the health sav­ings ap­proach in­to Medi­caid ex­pan­sion.”

“They’ve been at a pretty ser­i­ous im­passe there for quite some time,” he says.

The In­di­ana Medi­caid of­fice did not re­spond to a re­quest for com­ment.

MOST READ
What We're Following See More »
PROCEDURES NOT FOLLOWED
Trump Not on Ballot in Minnesota
3 days ago
THE LATEST
MOB RULE?
Trump on Immigration: ‘I Don’t Know, You Tell Me’
3 days ago
THE LATEST

Perhaps Donald Trump can take a plebiscite to solve this whole messy immigration thing. At a Fox News town hall with Sean Hannity last night, Trump essentially admitted he's "stumped," turning to the audience and asking: “Can we go through a process or do you think they have to get out? Tell me, I mean, I don’t know, you tell me.”

Source:
BIG CHANGE FROM WHEN HE SELF-FINANCED
Trump Enriching His Businesses with Donor Money
5 days ago
WHY WE CARE

Donald Trump "nearly quintupled the monthly rent his presidential campaign pays for its headquarters at Trump Tower to $169,758 in July, when he was raising funds from donors, compared with March, when he was self-funding his campaign." A campaign spokesman "said the increased office space was needed to accommodate an anticipated increase in employees," but the campaign's paid staff has actually dipped by about 25 since March. The campaign has also paid his golf courses and restaurants about $260,000 since mid-May.

Source:
QUESTIONS OVER IMMIGRATION POLICY
Trump Cancels Rallies
5 days ago
THE LATEST

Donald Trump probably isn't taking seriously John Oliver's suggestion that he quit the race. But he has canceled or rescheduled rallies amid questions over his stance on immigration. Trump rescheduled a speech on the topic that he was set to give later this week. Plus, he's also nixed planned rallies in Oregon and Las Vegas this month.

Source:
‘STRATEGY AND MESSAGING’
Sean Hannity Is Also Advising Trump
6 days ago
THE LATEST

Donald Trump's Fox News brain trust keeps growing. After it was revealed that former Fox chief Roger Ailes is informally advising Trump on debate preparation, host Sean Hannity admitted over the weekend that he's also advising Trump on "strategy and messaging." He told the New York Times: “I’m not hiding the fact that I want Donald Trump to be the next president of the United States. I never claimed to be a journalist.”

Source:
×