We’re starting to hit the point of no return for any states that want to expand Medicaid with a go live date of January 1, 2015. A state that is authorized to expand Medicaid in anything other than a straight up expansion probably needs a good three to four months to get initial operating capacity built out. They will need six to nine months to get everything working correctly after that. A state that is doing straight up expansion based on current configuration can go live with minimal hassles with a month’s notice.
So what is the state of play on Medicaid expansion for 2015.
Pennsylvania: (95% chance of going live 1/1/15):
Pennsylvania is pushing HealthyPA which is a premium support convoluted workaround to expansion that is needed to get Republicans (who occupy all the blocking positions) around Teabagger primaries. The state is still waiting for final approval from the Centers for Medicare and Medicaid Services (CMS). The state has told their Medicaid Managed Organizations to prepare as if Healthy Pennsylvania will be a go.
The plan is for the health insurers to offer commercial-like insurance to the newly eligible. The newly eligible will have some co-pays and deductibles for some services. This will look a lot like Arkansas or Iowa’s expansion rather than New York’s expansion.
Indiana: (95% chance of going live 1/1/15):
Indiana wants to expand their Healthy Indiana Plan to cover the entire Medicaid expansion eligible population. The HIP 2.0 (yeah, I wonder how much the marketing firm charged for this) plan is an HSA style plan with the state kicking in some of the deductible amount as well as required contributions to an HSA. People who don’t make the required contribution are out of the program for six months. People under the poverty line are pushed into a program that does not cover basic vision or dental.
As I said before, this proposal is better than nothing, but it should only be a starting point for conversations between Indiana and CMS. CMS has not issued a waiver yet. My inclination is that CMS will approve a modified waiver that will bring the acturial value of HIP 2.0 up to 95% or so, and Indiana can then proceed. Mechanically, the infrastructure is in place for HIP 1.0, so the insurers are doing back-end prep work now, and can probably do a fast launch once they get the final approval from Washington.
These are the two highly probable expansion launches. The next three are questionable expansions.
Wyoming (1/1/15 go live 0%, 7/1/15 go-live 75%)
Wyoming has decided that they want to start talking with the Feds about a Medicaid expansion waiver. This most likely means the state will want to go to a premium support model similar to Arkansas, Iowa, Pennsylvania and Michigan. No proposal has been put forward yet, so January 1 is an impossibility. However, if they don’t have too many bells and whistles, CMS has demonstrated an ability to rapidly turn around straight forward waivers, so July 1st is a decent guesstimate.
Virgninia (50% total probability of 2015 expansion, 10% for 1/1, 40% for 4/1)
Governor McAuliffe is calling a special session of the Virginia legislature this fall to focus on Medicaid expansion. He is facing Republican controlled House of Delegates and Senate. The goal is to create a coalition that is 100% of the Democrats and a small faction of Republicans who are seeing massive amounts of federal money passing the state by. Most likely that coalition will not be sufficient for straight up expansion. Instead a premium support model will probably be used.
I think it is a flip a coin chance for any expansion to pass. If Virginia goes premium support, a January 1 launch would be hyper aggressive (I don’t think they could get their waiver in time) and probably result in fiasco. A launch during the spring would give CMS time to issue a waiver, and allow for the construction of the needed backend infrastructure.
Maine (80% 4/1 launch if LePage is defeated)
If Gov. LePage is defeated in November, Maine will expand Medicaid straight up. Assuming enabling legislation is passed and signed in January, a March or April launch is highly probable.
Baud
The outlook is, where Dems are elected, people are better off.
John S.
@Baud:
It’s surprising how much of the electorate hasn’t figured this out yet.
low-tech cyclist
@John S.: In a political system that caters to the rich, pays some attention to the upper middle class, and largely ignores the needs and desires of everyone else, this isn’t exactly a surprise.
Still, it’s encouraging to see some gradual expansion happening.
WaterGirl
@Baud:
I think that would fit on a bumper sticker.
Richard Mayhew
@low-tech cyclist: The promising indicators are Wyoming and Indiana in that they are looking at the massive money flow going by them plus the loss of DSH payments to their providers. After the Supreme Court gutted Medicaid expansion, the hope has to be that Republican tilted states just want to get their hands on the massive money flows.
Maine is an anomoly of first past the post plurality problems in the electoral system– it is a state that typically would take expansion, no questions asked. Pennsylvania and Virginia are swingish states with strong political coalitions backing expansion. It is not too surprising that they want in.
ThresherK
Am I imagining things or is this becoming one of the more reliable places to read about the ACA, policy-wise?
(I cop to this possibly being not an “either/or” question.)
Richard Mayhew
@ThresherK: I try — I know that my strength is not reading the newspaper and go “I’M OUTRAGED”, but providing a bit more context and expertise to fairly arcane/confusing things in healthcare.
Tripod
Eventually the US will have universal coverage. In the mean time people will suffer and die because of an irrational hatred of melanin.
Redshift
I hope you’re right that the odds in Virginia are even that good; I’m somewhat pessimistic. Most of our state legislators are fully ensconced in the right-wing bubble, where Obamacare is still a complete disaster everywhere it had been implemented, and no actual facts can penetrate. An even worse tell came during the debate this spring, when it looked like a deal might be possible, but it was killed by House Republicans. Their leadership had forced them to accept a compromise on transportation in the previous session that included additional revenues, so their Republican governor could have a big accomplishment, and they were outraged at the idea that they were being asked to compromise *again*! The actual content of the deal barely entered into it; they just moved the goalposts with every proposal and demanded that they get everything and give nothing.
RaflW
@John S.: It’s unsurprising how much of the electorate hasn’t had a damn bit of help from major media to figure this out.
Richard Mayhew
@Redshift: My bet is the Virginia Hospital Assocation and the local docs will have some very long and pointed meetings with the Republican leadership and make the following very clear points:
1) The lack of Medicaid expansion is threatening the viability of the largest employer in their district
2) Medicaid expansion will relieve the state of significant charity care expenses
3) The state is still paying for it, might as well get something back
4) Expansion is a money maker — opposing expansion is a great way to see a well funded opponent in the next primary
Chris
How about Florida?
Richard Mayhew
@Chris: This is entirely a political judgement on my part, but the probability of expansion in the first half 2015 is very low.
1) This is indepedent of the Governor’s race as both candidates favor some flavor of expansion.
2) Will the composition of the State legislature change dramatically even if the change is internal to the Republican Party replacement of teabaggers with Republicans who can count to eleven with their shoes on?
I don’t know enough about Florida to say much about #2, but from what I’ve read, there is a low probability of a winning coalition of Democrats PLUS Republicans who can count to 11 when not in a TSA security line who don’t fear getting teabagged in the next primary being in place for the 2015 cycle.
geg6
@Richard Mayhew:
You have made the so-called wonk of the ACA, Ezra Klein, look like a piker. You are much more clear and have a much better grasp of what actual people using the system want to know. You are a national treasure, IMHO.
muddy
@geg6: A thousand times this.
rikyrah
@geg6:
WISH we had likes for this site, because I love this comment.
I’ll say it again…I’ve learned more about the ACA from Richard’s posts than anywhere else on the net.
Douglas Wayne Wieboldt
The Absolutely Amazing Asshole, Cutler is running as an independent in Maine, once again assuring Maine of a La Page extension. I’m moving.b I’d hoped that we had already hit peak wing-nut, but 4 more years will turn us into fucking mississippi…
Douglas Wayne Wieboldt
The Absolutely Amazing Asshole, Cutler is running as an independent in Maine, once again assuring Maine of a La Page extension. I’m moving.b I’d hoped that we had already hit peak wing-nut, but 4 more years will turn us into fucking mississippi…
Thoughtful David
@Redshift:
As another Virginian, I too am skeptical. I’d give it less than 1/10. Those kooks in the House of Delegates will never be convinced. There are some amazing Tealiban in there, and a pretty fair number of just plain idiots, who have never had two thoughts to rub together in their lives, and who will vote whichever way Rush Limbaugh tells them.
Thoughtful David
@muddy:
Seconded. Have seen nothing that comes close to your work, Richard.