Rachana Pradhan, a good health policy reporter with an ear for the mechanics, has an interesting tweet out on Wednesday afternoon:
Obamacare news: Arkansas’ @AsaHutchinson wants to keep expansion funding boost but limit eligibility to < 138% FPL. https://t.co/5U5hInp9yW
— Rachana D. Pradhan (@rachanadixit) January 11, 2017
Hold-out states run by Republicans are making noises about expanding Medicaid:
Scott in Florida asked for something very similar https://t.co/kpPSTlOCMA
— Dan Goldberg (@DanCGoldberg) January 11, 2017
Wisconsin hints it plans to take Medicaid expansion finally. https://t.co/R0oENGzRnB
— Emma Sandoe (@emma_sandoe) January 11, 2017
I hope that I put in writing somewhere a prediction that at least 10 of the 18 remaining hold-out states will have some type of Medicaid Expansion in place by 7/1/18 now that it is not Obama’s Medicaid Expansion. I know I said it at the office, but I want to point to where I wrote it down. These three tweets tie together.
Arkansas, as you know, has taken Medicaid Expansion through a 1115 waiver. It’s waiver has the state buy Medicaid Expansion eligible individuals on-Exchange policies. It works in that it gets coverage but it is an expensive to do so as commercial plans pay providers significantly more than Medicaid pays. This has not been too big of an issue for the first three years as the Federal government has paid the entire cost of the Medicaid expansion. However Arkansas is now on the hook for a small percentage of the incremental cost of Expansion. The 1115 waiver Arkansas has is more expensive to the state than if they just did a straight up expansion. So they are looking to cut costs by shifting the people who make between 100% to 138% FPL off of their Medicaid books and straight onto Exchange. Given how the waiver is set up, these people would be made no worse off as they were already paying premiums as if they were on Exchange. The difference is the federal government would cover the rest of the costs through advanced premium tax credits and cost sharing reduction subsidies instead of through Medicaid funds with a state matching contribution. People making under 100% of FPL would see no change either. It is a cost shifting exercise away from state obligations and towards federal obligations.
Now if Hillary Clinton had won, this would go nowhere. The Feds would say that Medicaid expansion was an all or nothing proposition; either everyone in the potential covered population got expansion or no one did. However in a Price/Verma that modification could be approved.
And if is approved, that is the route it seems like Florida and Wisconsin could go. People making over 100% of FPL would not be Medicaid eligible due to income and they would still be on Exchange for APTC and CSR but Medicaid would be expanded for those under 100% FPL with probably an Indiana style wrap-around 1115 HSA like waiver.
Now the questions is what is the counterfactual?
To me, it is either a convoluted and complex expansion or nothing. I’ll take convoluted and complex over nothing every day of the week.
rikyrah
Thanks for the explanation Mayhew.
Kristine
How does this mesh with repeal and block grant proposals? Do R governors care if the system is changed or are they just getting in line for the money?
Shantanu Saha
Now that the ni-clang is no longer in charge, they’re getting in line for the money, before it runs out.
rikyrah
@Shantanu Saha:
Tell that truth ???
Betsy
What is a counterfactual?
MomSense
Well the states that want to expand better hurry up. The Senate voted at 1:30 in the morning to make repeal of the ACA part of tbudget reconciliation. Judging from the floor speeches,they are going to repeal it without a plan to replace it.
The Amendment to wait until March failed so I think they will go ahead in January. 27th I believe.
satby
@MomSense: the chickenshits will pass repeal but delay implementation. They haven’t got a replacement and McConnell at least understands the danger of throwing their stupid red state voters off healthcare insurance with no replacement to cover how they’re screwing the rubes over.
satby
Anyone see much coverage about the GOP’s bill to prevent the CBO from scoring how much the repeal of the ACA will cost?
Richard Mayhew
@Betsy: Counterfactual — the universe as it would be without an intervention — the comparison group basically
Oatler.
Let’s clog the toilet and hope they will become disheartened trying to dig out the clumps. It’s worked before.
MomSense
@satby:
The chickenshits know damn well that repeal and delay will mean repeal and the exchanges collapse. Then they can blame ObamaCare for the failure.
I really cannot say how infuriated and heartbroken I am. Enzi – that fucking guy – went on and on about how repeal would provide relief to millions of Americans. When he started thanking his staffers for helping him I was just enraged with tears streaming down my face. His voice sounded so calm and happy. I can’t even begin to imagine the evil in that man’s heart.
MomSense
@satby:
Nope. Vichy press can’t be bothered. They have found a new interest in thoroughly vetting information before they release it.
Monsters.
rikyrah
@MomSense:
Nothing but evil
sunny raines
just rename Obamacare to trumpcare and it becomes the best healthcare law ever, unbelievable, a yuuuuuge improvement. no changes necessary, just repeal the name and pass legislation with the new name.
Barbara
When expansion was first passed, some states really wanted to scale it back so that Medicaid expansion eligibility would stop at 100% FPL (which varies by location), so that everyone above 100% FPL would essentially need to buy off the exchange. There would be no overlap population. You have to go deep into the weeds of Medicaid to understand what the real issues are here. The biggest issue is that there are some states for whom the Medicaid threshold is so stingy that the expansion would probably bring an enormous number of people into the system. Texas. The average state was at about 60% FPL, but the “uptake” for people who might have qualified varied a lot. So even though the expansion population was 100% paid for, the “original” population who all of a sudden found out that they should have been covered all along would definitely be a drag on state finances. A lot of states (probably Wisconsin among them) did not want to expand because they didn’t want to create an infrastructure to increase their original Medicaid population, for which they were not getting 100% federal money.
There are also pluses and minuses to doing it this way, just as there are pluses and minuses to doing it the way it was intended. First: the FPL percentages and eligibility populations are provided for by statute. There is a serious legal question whether HHS can approve a waiver that would in effect ignore the statute. Putting that aside, the issues fall out this way: Under the ACA as drafted, the policy choice was left to the individual as to whether their needs made Medicaid or private exchanges a better fit. There are many people whose income is sufficiently unstable that, even if it is 110% of the FPL this year (say) their health needs are sufficiently high that they require low out of pocket expenses and they might not be working as much next year. This might include parents of disabled children, or people working part time because they have serious health conditions. On the other hand, if you are a relatively healthy person with a low wage but fairly stable job, you might be better off just buying off the exchange, especially if you anticipate your income rising. Setting a lower threshold will also tend to lower the swings between the groups — there will be more Medicaid only and exchange only people. The swinging back and forth is an administrative burden and tends to disrupt care patterns. Some insurers, like Centene, are practically set up to deal with people who bounce between the two categories with minimal disruption to their care patterns. Medicaid status is already highly variable from one month to the next. It’s one reason why Medicaid doesn’t work as well as it should.
Anyway, lots of policy choices go into this issue and if lowering FPL for Medicaid expansion leaves Medicaid expansion otherwise untouched, that would count as a policy victory in my book.
rikyrah
@sunny raines:
Uh huh
Uh huh
Ruckus
@sunny raines:
They don’t want to be saddled with the positive results. That’s why they named it Obamacare in the first place. They don’t want responsibility for positive government. Government must fail, that is their foundation, their entire reasoning, government must fail. Because if it doesn’t they have, in their tiny fucking minds, no power. No power to control who they want, No power to hate who they want, No power to be fascists.
Karen
What is FPL?
Weaselone
FPL = Federal Poverty Level
MazeDancer
Hospital administrators informed Hutchison without ACA, the losses from unpaid ER visits were going to close rural hospitals. And that with ACA, those hospitals can function. Arkansas is a small state, not as hard for Hutchison to be shown the facts. And know that he would be responsible for closed hospitals.
Weaselone
Given the votes in the Senate last night, I’m pretty sure Obamacare is gone.
Katdip
So much for the party of fiscal discipline and business savvy. We somehow need to tie this to the Republican brand of “Less for More!” They always seem to find a way to provide less service for more money, lining the pockets of their corporate overlords while sticking us with the bill. When NH debated a similar plan for providing insurance instead of FFS Medicaid, it was a weird Alice-down-the-rabbt-hole debate as the Rs in that fiscally conservative state tried to explain why it made sense to spend the the same amount of money and cover 1/3 fewer people. “Freedumb”or some such nonsense. Sadly too many perk up at that dog whistle….
Barbara
@Weaselone: Susan Collins, Cory Gardner, and Dean Heller deserve to pay with more than their careers for their votes.
Barbara
@Katdip: Right, something like: Let’s pay insurers in order not to provide insurance coverage. It’s not just cruel, it’s stupid.
Barbara
@Barbara: Also, I forgot to mention — insurers like the higher thresholds because of the relative instability of this population, and the failure to adopt Medicaid expansion is one of the key drivers in making the exchange pools unpredictable and arguably sicker than insurers were counting on. Basically, there is a population of people whose relationship to the workplace is sufficiently tenuous that they have more in common with traditional Medicaid populations even if their income in one year might surpass an FPL threshold.
ETA: Most people in the Senate and House have no business savvy. Even if they are wealthy, they have zero understanding of the insurance business. That goes double for the health care providers among them, whose knowledge of insurance is highly biased by their own professional priorities.
ArchTeryx
Looks like I better start my end-of-life planning in earnest.
MomSense
@ArchTeryx:
I’ve been crying on and off since I watched that mess live last night. I’ve been thinking of you having to make end of life plans and I am just so angry and sad. Another friend of mine is doing the same. This is such a tragedy.
Barbara
@ArchTeryx: I don’t know your situation, but let me just offer best wishes and say that I hope not, I hope that your end of life plans are not forced on you because of the cruel and senseless actions of our government.
ArchTeryx
@Barbara: I’ve got an autoimmune disease, Ulcerative Colitis, combined with an artificial colon (J-pouch) which is maintained with a medicine that costs $2500/month. Not to mention the frequent doctor visits necessary to adjust medicines and check the pouch.
Take all that away, and what follows is blind agony, followed by almost certain sepsis and death. My friends and family are all working furiously to look for alternatives, but $2500 a month is an incredibly steep hurdle to climb, and nobody is going to GoFundMe that forever. Even if they were, doctors visits are not an optional part of the maintenance; without them, my lifespan is prolonged, but not saved.
So I’m looking for a painless way out. My doctors may even help me in that. They care far more then the rest of the country does.
Barbara
@ArchTeryx: I’m really sorry. Can I get you to tell me the name of the manufacturer of the drug? You have probably already investigated charitable means to obtain it, but I am really resourceful and it won’t hurt for me to look. If not, I totally understand as well.
ArchTeryx
@Barbara: Canasa. Mesalamine is the generic. Canasa, however is the *only* form of it that exists as a suppository and it can’t be compounded in a drugstore. The only reason Medicaid pays for it – despite it being brand name at full price – is because there’s literally no alternative.
It goes beyond just that one drug, though. The doctors visits are also a part of it, to adjust the dose and make sure the pouch isn’t starting to fall apart on me. Losing doctors visits but keeping the med will keep me going longer, but not that much longer.
ms_canadada
@ArchTeryx: I hope you don’t mind, but knowing drug prices are much cheaper in Canada, I looked up your medicine on pharmacy checker dot com. The cost of ninety, one thousand milligrams suppositories is 249 Canadian dollars. I hope this information helps. Best regards.
Gretchen
Here in Kansas many of the new legislatures who ran against the Brownback agenda want to expand Medicaid. There are hundreds in the state Capitol today protesting Brownback’s budget priorities. The Facebook posts by our Senators and Representative about repealing the ACA each have one or two positive responses, and a flood of responses against repeal.