The House Energy and Commerce committee came out with their reconciliation mark-up. This committee has quite a bit of jurisdiction including responsibility for Medicaid and the CHIP program for kids. The health finance, coverage and insurance portion of the bill is only 36 pages and it has some big policy proposals.
- No beneficiary cost sharing and federal financing of all Medicaid administered/covered COVID vaccines.
- Option for states to extend Medicaid eligibility that derives from pregnancy from the current 60 days post-partum to a year
- Standard federal financing (FMAP)
- Allows for people who are to be released from incarceration to become Medicaid eligible 30 days before their release dates
- Big deal in reducing transitions of care and discontinuities of medication and treatments due to financing problems
- Paying states to expand Medicaid with a 5% FMAP bump for Expansion Medicaid for 8 quarters
This last piece is fascinating.
Right now the Medicaid program from a state financing perspective can be thought to have two main components. The first is Legacy Medicaid. This is mostly Medicaid as it was structured in 2009. Legacy Medicaid covers pregnant women, aged, blind and disabled, low income kids, long term services and supports and nursing home room and board for dual eligible individuals as well as a a few other eligibility groups. There are income and often asset limits.
Legacy Medicaid is a big line item in any state budget. In Fiscal Year 2019, North Carolina spent $3.8 billion dollars in state funds on Legacy Medicaid. The state pays a share and the federal government pays a share. The federal share is known as FMAP. FMAP is a function of the state’s wealth and income. North Carolina’s baseline split with the federal government for Legacy Medicaid is about 1:2. Massachusetts has a 1:1 split with the federal government while Mississippi has a baseline split of almost 1:3. During the COVID public health emergency, the federal government has enacted an across the board 6.2% point increase in the federal share for Legacy Medicaid. Federal dollars replace scarce state dollars. It is a means to deliver financial relief to state government budgets which are structurally challenged from borrowing to finance counter-cyclical and disaster relief spending.
We also have ACA Expansion Medicaid. Expansion Medicaid is voluntary due to the Supreme Court’s 2012 NFIB v Sebelius decision. Expansion Medicaid covers otherwise ineligible folks who earn up to 138% of the Federal Poverty Level (FPL). The federal government started paying 100% for Expansion Medicaid in 2014. It now pays 90% of the costs. From a state budget perspective, Expansion Medicaid is almost to completely cost neutral as states are able to recategorize enough beneficiaries from other healthcare programs to be part of expansion Medicaid that the state spend on new enrollees is balanced by the transfer of people from programs that were 25%, 35%, 50% or 100% state spend to a program that is now 10% state spend.
The House E&C committee proposes to pay hold-out states an enhanced FMAP of 95% for eight quarters for the ACA after they expand Medicaid. There have been several other proposals in Congress over the past eight years to incentivize states to expand Medicaid. Any of those proposals, including the latest from E&C, makes Expansion extremely likely to be state budget neutral if not state budget positive.
If this mostly makes it through the Senate, the offer has to be tempting to at least several of the hold-out states.
Cameron
I wish they’d sign on here in Florida. Other than pure ideology – screw the Poors – it makes no sense. Unfortunately, it doesn’t appear that COVID-19 has led to an outbreak of intelligent policy-making in Tallahassee.
Benw
We’re not just doing this for money.
We’re doing it for a SHITLOAD of money!
L85NJGT
After reading about the difficulty industry lobbyists had in explaining coal power plant write downs to state legislators, and seeing the paranoid refusals on Medicaid expansion, I think we have crossed the derp horizon. Gerrymandering and term limits have cut GOP state parties off from reality. Instead of creating state leges easily controlled by the big money, they created a zombie party that wants brains!
Go through a list of hospital closures over the last decade. It is heavily skewed to be recalcitrant Medicaid states, where state legislators apparently want their constituents to not only have a lack of employment opportunities, but straight up die.
Marcelo
Yeah they could offer to pay for it 100% forever and some states still wouldn’t take it. I appreciate the flexibility and willingness to offer incentives, but we are not dealing with good faith actors who want a good deal, who are legitimately concerned with cost. Cost is a front, a goalpost to be moved. They just wanna punch hippies, own libs, and hoard money.
Another Scott
@Cameron: Here in VA, the GOP-controlled legislature fought expanding Medicaid every step of the way. Until Gov. Northam was elected – the expansion was signed into law in May 2018 (as part of the ’19-’20 state budget). Obviously, the economics didn’t change – it was the politics.
FTFNYT (from 2018):
I believe the work requirements are being removed under Biden, or may have been removed by the state already, but I haven’t checked to be sure.
People have to be able to vote for their representatives and have their voices heard. That’s why at the base of all sensible policy is voting rights.
Cheers,
Scott.
Joe Falco
@Cameron: Same for Georgia. It would take a clean sweep in the statehouse and governor’s races for Democrats and even then I’d expect Republicans to pull some crap to prevent Democrats from expanding Medicaid once in power. Not to say it isn’t worth fighting for, but Georgia Republicans have shown they will do anything it takes to prevent poor people from having a better life.
Cameron
@Another Scott: Agree absolutely about voting rights. Florida is an excellent example – the voters re-enfranchised ex-cons by a pretty convincing majority…..only to have the state legislature undermine their decision.
lowtechcyclist
@Marcelo:
This. Politicizing this makes about as much sense as politicizing mask-wearing, and they’ve done both.
If the Dems passed a bill that fully funded solar panels on everyone’s roof, free for the asking, I bet at least 30% of Americans would turn it down because it was a Dem bill, and because solar power is a librul idea.
patrick II
I am not a lawyer, but I thought Expanded Medicaid was allowed to be a state option due to a very strained reading of the law that asserted Expanded Medicaid was a separate program from Medicaid (not what congress intended at all) and therefore change to the wording of the law that would merge the state’s requirement for Expanded Medicaid into traditional Medicaid requirements and making the program whole. Even the two Democratic judges who voted for the strained reading (we always suspected, but found out later through reporting) only did so in a bargain with Roberts to save ACA. So, bottom line, I thought Expanded Medicaid could be re-integrated into Medicaid with just some straightforward, unambiguous lawyerly language. It doesn’t hurt to put a few carrots in there as well, but changing to make in a necessary part of Medicaid seems to help solve the problem as well.
Matt
No, it won’t. The budget arguments from the holdouts are 100% lies, and anyone still taking them at face value is either a fool or a wingnut.
We could make it so that legislators that expand Medicaid in their state each _personally_ get a billion dollars and they still wouldn’t do it. They WANT people to get sick and suffer, it’s the central sacrament of their religion.
Bob Hertz
The cpmmenters above are correct that some states will resist Medicaid even if it is free to them.
A main reason is that Medicaid gives poor people just one more reason to stay where they are. The conservative legislators want poor people to move out of their state.