Reform Update: Proponents of Medicaid expansion weigh next moves

As many state legislative sessions have finished or are nearing completion, advocates of expanding Medicaid eligibility are looking at their next steps.

Expansion of Medicaid eligibility as called for by the 2010 healthcare overhaul will not happen in 19 states, and seven more states are leaning against expanding, according to the latest estimates by Avalere Health.

But the failure of the expansion to pass in many recently or nearly concluded state legislative sessions is unlikely to spell the end for those measures. Advocates in many states already are discussing plans for bringing the expansion up again in special legislative sessions or putting the expansion directly to voters. Others expect the legislatures could take multiple years to come around in support of growing their Medicaid programs.

Joy Wilson, health policy director for the National Conference of State Legislatures, said the 2013 legislative session likely laid the groundwork for reluctant legislatures to pass the expansion next year—when states will have lost only one year of the three-year 100% federal funding for expansion.

“I think some states will reconsider next year,” Wilson said.

For instance, the Missouri legislature—which rejected Democratic Gov. Jay Nixon's repeated efforts to pass a Medicaid expansion—plans to convene a committee to study the issue before the 2014 session.

Meanwhile, advocates for expansion in some states, including Iowa and Ohio, also have voiced some support for voter referendums. The ballot push is based on the belief that voters are more supportive of the expansion than Republican legislators, who have generally opposed adding millions of new beneficiaries to a program they view as costly and a poor insurer.

The ballot push may get a boost in some conservative states from recent polling that found broad support for Medicaid expansion. Sixty-two percent of voters in Alabama, Georgia, Louisiana, Mississippi and South Carolina supported the Medicaid expansion, according to polling released Tuesday by liberal Families USA. That support came despite a pluralities' opposition to the overall law, which generally mirrored national polls.

But advocates of expansion do not all support taking the issue to the voters.

Peter Wertheim, a spokesman for the Arizona Hospital and Healthcare Association, said the state's hospitals oppose a ballot initiative over the legislature deciding on it. The state Senate passed a Medicaid expansion, but it ran into opposition in the House, where Speaker Andy Tobin has urged it be sent to the voters.

“We elect our legislators to get this job done,” Wertheim said.

The referendum route would push back a decision on the bill until the fall, reducing needed implementation time and adding the costs of a potentially pricey campaign, he said.

Instead, hospitals and their allies in the state—under the umbrella group Restoring Arizona—are using rallies, and advertising to push reluctant House Republicans to approve the expansion.

Iowa lawmakers deadlocked

Iowa legislators remain deadlocked over a Medicaid expansion, as its legislation session nears its end, according to the Associated Press.

Lawmakers have not found a compromise on whether to expand Medicaid or to pass an alternate healthcare plan offered by Republican Gov. Terry Branstad. Some legislators have discussed the possibility of concluding the session without finishing the debate and to return later on that issue in a special session.

Democrats, who control the Senate, have advocated on behalf of Medicaid expansion, while Republicans running the House prefer Branstad's plan to revamp an existing program for low income Iowans.

A Democratic alternative for repaying Medicaid costs to hospitals and expanding the program could go to the Maine Legislature this week, the Associated Press reported.

Democrats said the Medicaid expansion, which would be fully funded initially by the federal government, would save money by lowering hospital spending for “charity care.”

Republicans, who've proposed creation of a panel to study Medicaid expansion, said previously that expanding coverage to an additional 60,000 to 70,000 Mainers could end up costing the state $100 million every two years.

The Illinois House began consideration of the Medicaid expansion, the AP reported.

Under legislation that's already passed the Senate, up to 500,000 uninsured Illinois residents would be newly eligible for coverage, with the federal government paying for their care the first three years. Illinois officials expect 342,000 people to enroll by 2017.

Republicans say they have concerns about future costs, and are especially worried that the federal government eventually will shift more of the costs to the states.

Follow Rich Daly on Twitter: @MHrdaly