The affordable care act and the politics of the medicaid expansion

New Political Science

Volumn 37, Issue 3, 2015, Pages 295-320

  Olson, Laura Katz ^a  

^a LEHIGH UNIVERSITY   (United States)

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EID: 84943350643     PISSN: 07393148     EISSN: 14699931     Source Type: Journal    
DOI: 10.1080/07393148.2015.1056428     Document Type: Article

References (62)

1. Public Law 111-148 (ACA) and H.R. 4872 (Reconciliation Act).
2. Nearly 82% of the Medicaid expansion population is adults who are not living with dependent children. Genevieve Kenney, Stephen Zuckerman, Lisa Dubay, Michael Huntress, Victoria Lynch, Jennifer Haley and Nathaniel Anderson, Opting in to the Medicaid Expansion under ACA: Who Are the Uninsured Adults Who could Gain Health Insurance Coverage (Washington, DC: The Urban Institute, August 2012).
3. National Federation of Independent Businesses (NFIB) v. Sebelius, 132 S. Ct. 2566 (2012).
4. In 2011, the US devoted $2.7 trillion for health services (17.9% of GDP) yet had 47 million people uninsured, nearly one-sixth of the population.
5. Reauthorization under the George W. Bush administration had been a struggle, however, and the president vetoed the legislation twice. It was only with the election of Barrack Obama that SCHIP-renamed CHIP-survived.
6. Colleen M. Grogan and Eric M. Patashnik, "Universalism within Targeting: Nursing Home Care, the Middle Class, and the Politics of the Medicaid Program," Social Science Review 77:1 (2003), pp. 51-71.
7. Robert E. Hurley and Stephen A. Somers, "Medicaid and Managed Care: A Lasting Relationship?" Health Affairs 22 (January 2005), pp. 77-88.
8. Rebecca Adams, Boom in Managed Care Alters Medicaid Calculations, The Commonwealth Fund, "Washington Health Policy Week in Review (New York, August 11, 2014), available online at: www.commonwealth.org/publications/newsletter/ washington-health-policy-in-review/2014/August/Aug-11-2014/boom-in-managed-care.
9. In particular, the Social Security Act's Section 1115 waiver provision encourages state "experimentation" by allowing them to disregard certain federal stipulations as long as their demonstration projects are budget neutral.Waivers are in force for three to five years, but can be renewed.
10. Authority for these waivers is under Title X1X of the Social Security Administration's Section 1115 that gives the Secretary of HHS authority to waive provisions of major health and welfare programs authorized under the Act, including certain Medicaid requirements, and to allow a state to use federal Medicaid funds in ways that are not otherwise allowed under federal rules.
11. Specific state FMAPS by year can be found at US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, available online at: http://aspehhs.gov/health/fmap.cfm.
12. It would also newly insure over 70,000 people during that period. Families USA, Florida's Economy Will Benefit from Expanding Medicaid (Washington, DC, February 2013), available online at: http://familiesusa.org.
13. Montana Budget and Policy Center, Healthy Montanans Build a Healthy Economy (Helena, MT: Montana Budget and Policy Center, updated January 28, 2013), available online at: www.montanabudget.org.
14. Health Policy Institute of Ohio, Fact Sheet: The Impact of Not Expanding Medicaid in Ohio April 2013, (Columbus, OH: Health Policy Institute of Ohio, April 2013), available online at: http://www.hpio.net/medicaid.
15. At the same time, 340,000 uninsured people would gain immediate health coverage, and by 2022 a total of 719,000 people would achieve insurance. Independent Pennsylvania Health Care Cost Containment Council, Financial Analysis Fiscal Year 2012, Volume one: General Acute Care Hospitals (Harrisburg, PA), May 2013, available online at: http://www. phc4.org/reports.
16. It would also assist 330,000 uninsured people. Eric Whitney. Colorado Medicaid Expansion Moves Forward with One Republican Vote, Kaiser Health News (Menlo Park, CA.: Henry J. Kaiser Family Foundation, Kaiser Commission on Medicaid and the Uninsured, April 29, 2013), available online at: www.capsules.kaiserhealthnews.org.
17. Joseph Antos, "The Medicaid Expansion is Not Such a Good Deal for States or the Poor," Journal of Health Politics, Policy, and Law 38:1 (October 2012), pp. 179-186.
18. Center on Budget and Policy Priorities, Guidance on Analyzing and Estimating the Cost of Expanding Medicaid, (Washington, DC, August 9, 2012).
19. It is estimated that states would gain about 10 percent of any reduction in uncompensated care. However, the greatest savings accrue to the New England and Mid- Atlantic states. John Holahan, Matthew Buettgens, Caitlin Carroll, and Stan Dorn, The Cost and Coverage Implications of the ACA Medicaid Expansion: National and State-by-State Analysis (Menlo Park, CA.: Henry J. Kaiser Family Foundation, Kaiser Commission on Medicaid and the Uninsured, November 2012), pp. 1-56.
20. Laura Katz Olson, The Politics of Medicaid (New York: Columbia University Press, 2010).
21. Stuart Altman and David Shactman. Power, Politics and Universal Health Care (Amherst, NY: Prometheus Books, 2011).
22. Austin B. Frakt and Aaron E. Carroll. "Sound Policy Trumps Politics: States Should Expand Medicaid," Journal of Health Politics, Policy, and Law 38:1 (2013), pp. 165-178. Hill-Burton facilities also must participate in Medicaid, which tends to pay less than both Medicare and private insurance.
23. Families USA, Florida's Economy, p. 5.
24. Independent Pennsylvania Health Care Cost Containment Council, Financial Analysis 2012.
25. The original Medicaid DSH reductions were altered by the Bipartisan Budget Act of Beginning in 2016, they will be decreased by $1.6 billion in 2016, $1.8 billion in 2017, $5 billion in 2018, $5.6 billion in 2019 and $4 billion in 2020. Correspondingly, Medicare DSH payments will be reduced by over $22 billion between 2014 and 2019, although a portion of the savings will be diverted to hospitals with the largest percentage of uncompensated care.
26. Holahan, Buettgens, Carroll, and Dorn, The Cost and Coverage Implications of the ACA Medicaid Expansion (Washington, DC: Henry J. Kaiser Family Foundation, Kaiser Commission on Medicaid and the Uninsured, November, 2012), pp. 1-56, available online at: http://www.urban.org/sites/default/files/alfresco/publication-pdfs/412707- The-Cost-and-Coverage-Implications-of-the-ACA-Medicaid-Expansion-National-and- State-by-State-Analysis.PDF.
27. Jay Hancock. Insurer Centene: We Can Do Arkansas-Style Medicaid, Kaiser Health News (Menlo Park, CA.: Henry J. Kaiser Family Foundation, Kaiser Commission on Medicaid and the Uninsured, April 23, 2013), available online at: www.capsules.kaiserhealthnews.org.
28. Among the strongest supporters are the Chamber of Commerce associations in Texas, Idaho, Virginia, Alaska and Pennsylvania. Those in North Carolina and Georgia are somewhat less enthusiastic.
29. Penalties are up to $3000 per worker.
30. New England Cable News, "Medicaid Expansion Debate Ahead in Illinois House," May 16, 2013, available online at: www.NECN.com.
31. US Department of Health and Human Services, Centers for Medicare and Medicaid Services, Office of the Actuary, 2011 Actuarial Report: On the Financial Outlook for Medicaid (Washington, DC: US Department of Health and Human Services, 2011).
32. Holahan, Buettgens, Carroll, and Dorn, Cost and Coverage Implications, pp. 2, 21, 33-34.
33. US Department of Health and Human Services, Medicaid and CHIP: May 2014 Monthly Applications, Eligibility Determinations and Enrollment Report, Centers for Medicare and Medicaid, July 11, 2014, available online at: http://Medicaid.gov/AffordableCareAct/ Medicaid-Moving-Forward-2014/.
34. Center on Budget and Policy Priorities, Guidance on Analyzing and Estimating the Cost of Expanding Medicaid.
35. After the election, only Indiana's HHS-approved waiver was accepted by its state legislature.
36. If one party has a majority in both the House and Senate, that party is considered as having legislative control in the state.
37. For Democratic-led states, greater wealth and experience with waivers have fostered quicker and more extensive reforms, such as in the case of implementation of the Medicaid expansion. Timothy H. Callaghan and Lawrence R. Jacobs, Dynamic Federalism and the Implementation of the Affordable Care Act, paper prepared for the 2013 Annual Meeting of the American Political Science Association, August 29-September 1st, 2013, Chicago, IL.
38. The nine variables included partisan control of government; the role of interest groups; economic conditions; bureaucratic capacity; percentage of population uninsured; annual growth in health care spending; per capita federal funding for the exchange; and decisions by neighboring states. Renee J. Johnson, David P. Randall, and Aroon Manoharan, Policy Innovation and Government Performance: The Implementation of State Health Insurance Exchanges, paper prepared for the 2013 Annual Meeting of the American Political Science Association, 29th-September 1st, 2013, Chicago, IL.
39. John Hudak. "Give Me Liberty or at Least Your Votes: A Study of Governors' Altruism on Health Care," Research Paper (Washington, DC: Brookings Institution, July 5, 2012).
40. Frakt and Carroll, Sound Policy.
41. Data calculated from Henry J. Kaiser Family Foundation, State Health Fact, Population Distribution by Race/Ethnicity, States:2010-2011 (Menlo Park, CA: Henry J. Kaiser Family Foundation, Kaiser Commission on Medicaid and the Uninsured, November 2012), available online at: www.statehealthfacts.org.
42. Any discussion of an expansion is off the table for 2015 despite Governor Jay Nixon's (D) re-election.
43. In January 2015, its governor, Steve Bullock (D), introduced Healthy Montana-but the General Assembly is still balking. If enacted, the state would contract with a private administrator (such as an insurance company) to process and run a network of providers for the newly-covered Medicaid population.
44. During the early stages of the Medicaid expansion debate, Virginia's Republican governor, Bob McDonnell, had proposed several conditions to HHS as a prerequisite for supporting the expansion. Even before the negotiations were completed, the legislature adjourned without opting in. With the November 2013 election of Terry McAulife, a Democrat, there was now strong support at the executive level, even though he faced a resistant Republican-controlled legislature. Three months later, the Senate unveiled a private sector approach ("Marketplace Virginia"); however, the House remained determined to block any proposal. The stand-off between the legislature and governor McAulife (D) generated a fierce battle over the state's two-year budget, including the threat of a government shut-down. Determined to move forward with the expansion, McAulife threatened unilateral executive action but he eventually backed down. Early in 2015, the Virginia legislature put an end to any discussion of a Medicaid expansion in any form.
45. In the November election Governor Beebe was replaced by a Republican, along with gains in the number of Republican legislators. Thus far, the new governor has indicated that he intends to renew the expansion, possibly with revisions. By Arkansas law the legislature must re-authorize the expansion every year by a 75% majority.
46. The additional Medicaid recipients will receive premium subsidies either for an employer-based plan, if available, or for insurance purchased via the health care exchange. The bipartisan agreement must be renewed at the end of 2016 and, since the November the Republicans control both chambers of the legislature.
47. The governor had remained undecided for several months, awaiting the results of a study he had commissioned. After reviewing the report's positive assessment, he forged ahead. Republican opponents requested a temporary injunction to stop him from carrying it out but the court ruled in favor of the governor.
48. In a decision ostensibly unrelated to the Medicaid expansion, Florida Republican leaders received their long sought after Medicaid waiver from HHS early in 2013. It allowed them to transfer all Medicaid recipients into Managed Care Organizations (MCOs), a controversial action given the myriad problems plaguing the ongoing five-county MCO Demonstration Projects. Almost immediately, in what appeared to be a quid pro quo, Governor Scott agreed to support the Medicaid expansion for a three-year trial period, during which time the federal government would pay all of the costs. However, as discussed later, the governor has been unable to convince his Republican-controlled legislature to go along with him. Nevertheless, the MCO waiver is being implemented.
49. The Arizona Health Care Cost Containment System already covers all households with income up to 100% of the FPL (1.3 million people) through private health plans; however, many childless adults had lost their Medicaid insurance because of budget deficits in 2011 and 2012. The enactment of the Medicaid expansion will reinstate them, and add new recipients with household income between 100 percent and 138 percent of the FPL. A number of Republican legislators, along with other opponents of the expansion, attempted to gather signatures in order to take the issue to a referendum; the effort failed to reach the required number. They have now taken it to court, challenging the legality of the new hospital tax that is expected to pay for much of the state share of the expansion. Thus far, an appeals court has upheld their standing to sue but the governor is challenging that decision. Still determined to restrict, if not stop the expansion, in April 2014 the house Republicans enacted a bill that would have forced able-bodied Medicaid recipients to get a job and limit some people to a maximum of five years of coverage.
50. The seven opposing Southern Republican governors include Alabama, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, and Texas. The other four southern states are Arkansas, Florida, Tennessee and Virginia. In Mississippi, because of partisan squabbling over the extension, the legislature ended its 2013 session without any funding for the Medicaid program at all, potentially leaving 640,000 residents uninsured. Governor Bryant, while opposed to the expansion, had vowed to continue the state's Medicaid program on his own through an executive order despite a ruling by the Attorney General that he does not have the legal authority to do so. At the end of June, after legislators agreed to vote on the extension-which lost-they approved reauthorization of the Medicaid program. The governor of South Dakota (with the support of his legislature) had requested a limited Medicaid expansion of up to only 100 percent of the FPL but HHS rejected it.
51. In Georgia, Kansas, North Carolina, Texas, Utah and Wyoming, opposition was so strong that, despite concurrence with their governors, the legislatures enacted bills prohibiting the Medicaid expansion without their explicit approval. However, recently the governor of Wyoming has been instructed to explore marketbased possibilities with the federal government that he presented to the legislature when it reconvened in January 2015.
52. Moreover, individual Republican legislators in several states that have not adopted the expansion, including Louisiana, are urging an Arkansas- type model. In Oklahoma, one recommendation has been to expand the "Insure Oklahoma" program which currently uses state and Medicaid dollars to help about 30,000 to purchase a bare minimum private insurance policy.
53. In March 2014, a recalcitrant Tennessee legislature enacted legislature that gave it final approval for any agreement between the governor and federal government.
54. In November 2013, a Utah legislative panel offered three potential options: keep Medicaid as is; partially increase eligibility for the program up to 100 percent of the FPL, with the rest of the expansion population purchasing subsidized insurance on the exchanges; and partially raise the eligibility level for Medicaid up to 100 percent of the FPL but utilize Medicaid money to purchase private insurance for the rest of the expansion population.
55. In Nebraska, the governor left it to the unicameral, non-partisan Assembly, which turned it down. In 2014, Nebraska legislators proposed a bill, Wellness in Nebraska, based on limited private insurance option but the governor opposed it and the act failed to pass.
56. The program already severely limits the types of available services and the venues for receiving them.
57. The agreement also includes premiums up to 2% of annual income that could be waived if beneficiaries participate in health assessments, annual physicals and other stipulated activities. Beneficiaries will be charged a co-payment for non-emergency ER care as well. Iowa ultimately received a federal waiver for its hybrid approach.
58. In an attempt to induce the governor to accept the expansion, the legislature added a 2016 time limit but Le Page vetoed it nonetheless. An override attempt lost by two votes in the House. As a result of the November election, however, Maine now has a Republicancontrolled Senate and thus it seems even less likely that the state will support a Medicaid expansion in the near future.
59. Kenney, Zuckerman, Dubay and Huntress, et al. Opting in to the Medicaid Expansion under ACA, 1.
60. Children and pregnant women are much less likely to lack health insurance; fully 99 percent of the newly eligible population is adults. Twenty-six states offer Medicaid or CHIP to children with household income up to 250 percent of the FPL, and only four states have thresholds under 200 percent of the FPL. No state has eligibility levels lower than 100 percent of the FPL for children. Every state offers Medicaid to pregnant women with household income of at least 133 percent of FPL and 16 states provide it to them with household income at or above 185 percent of the FPL. Holahan, Buettgens, Carroll, and Dorn, The Cost and Coverage Implications of the ACA Medicaid Expansion, p. 4.
61. Kenney, Zuckerman, Dubay and Huntress, Opting in to the Medicaid Expansion under ACA, pp. 1-19.
62. Meanwhile, in December the state had received HHS approval for a revised plan.