Rachana Pradhan, a good health policy reporter with an ear for the mechanics, has an interesting tweet out on Wednesday afternoon:
— 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.