And while the CBO numbers are not a reality, the figures are “already coloring the conversation,” Siegel said, adding that he's especially worried about Florida, Louisiana and Texas, states in which the governors have said they won't expand Medicaid and where many uninsured people rely on the safety net. Siegel said his organization gives the numbers “a lot of weight” because the CBO report was the first independent assessment of the future of Medicaid expansion.
He cited the CBO's predictions that many states either won't expand their Medicaid programs or won't expand them for years—along with the finding that fewer people will be covered under Medicaid—as his greatest concerns.
Some Washington policy experts—including Douglas Holtz-Eakin, a former CBO director—bemoaned the uncertainty of the estimates, which the CBO itself acknowledged. Analysts from both the CBO and the Joint Committee on Taxation did not use state predictions, but instead projected “approximate shares of the affected population” who live in states that fit into broad categories ranging from no expansion to an expansion that the healthcare law envisioned.
The analysts estimate that in 2022 about one-third of the potential newly eligible population will live in states that decide to extend coverage fully for up to 138% of the federal poverty level, while about one-half of the potential newly eligible population will live in states that partially extend Medicaid coverage to an income threshold less than that level. That leaves the remaining one-sixth living in states that will not extend Medicaid coverage at all in the next 10 years. And the CBO and Joint Committee on Taxation predict that coverage expansions will unfold in such a way that one-third of people who are newly eligible will reside in states that expand in 2014. Another third, they estimate, will live in states that wait until 2015, and the remaining third will reside in states that delay expansion longer.
Meanwhile, DSH payments are among the myriad questions related to Medicaid expansion that hospitals have for the Obama administration. A day before the CBO released its report, several hospital groups met privately with HHS and CMS officials, including HHS Secretary Kathleen Sebelius and CMS acting Administrator Marilyn Tavenner, to discuss issues about the Medicaid expansion.
Siegel attended and said HHS convened the meeting to keep “lines of communication open” among stakeholders. Richard Umbdenstock, president and CEO of the American Hospital Association, and Teri Fontenot, president and CEO of Baton Rouge, La.-based Woman's Hospital who chairs the AHA board, also attended. Fontenot was unavailable for an interview, but Tom Nickels, the AHA's senior vice president for federal relations—who did not attend—said HHS is engaging a variety of stakeholders to lobby state legislators to expand Medicaid.
“That was the whole purpose,” Nickels said. “That is certainly something our members would like to see happen.” In a brief notice to its members, the AHA said the July 23 meeting covered “many yet-to-be answered questions concerning federal and state negotiations, advocacy at the state level, the connection between coverage and payment reductions, and how other issues in the ACA may affect the expansion.”
HHS has already answered one big question for providers. After the Supreme Court ruling, many wondered whether states would be able to miss the law's 2014 deadline for expanding Medicaid coverage and still receive the higher federal funding match promised to states that comply. “The answer was yes,” Nickels said.