Medicaid debate turns to when expansion occurs

The Michigan Senate's intense, months-long debate over Medicaid expansion and the federal healthcare law is not over, even after the Republican-controlled chamber's milestone vote to provide health insurance to hundreds of thousands of low-income residents.

Senators on Tuesday will reconsider the issue of when the legislation should take effect. While the Senate passed the bill 20-18 in dramatic fashion, it fell two votes short of the 26 needed for immediate effect.

For an estimated 320,000 newly eligible adults counting on the medical coverage next year, it means waiting until late March or early April instead of qualifying as early as Jan. 1. It also could cost the state—which is taking the U.S. government's offer to pay the entire cost of expansion for the first three years—$64 million in savings primarily associated with paying mental health and substance abuse treatment costs with federal dollars.

Republican Gov. Rick Snyder, for whom Medicaid expansion is a major legislative priority, said he hopes that when the "dust all settles" after last Tuesday's vote, more Republicans will agree to let the bill go into effect in January even if they voted against the measure itself.

Four Republicans of the 18 voting "no" did that.

"Should we make people wait three more months for the opportunity to get this coverage? I'm not sure the benefit of the three-month wait," Snyder said.

Since winning a supermajority in 2010, Senate Republicans typically have been united in letting proposed laws have effect immediately when such votes are held. The votes are seen as "procedural" and a chance to stick together when passing bills along party lines over Democrats' objections.

Every GOP senator agreed in December to put contentious emergency manager legislation into law immediately even though some Republicans voted against the bill. The law ultimately took effect in March because the House did not grant it immediate effect.

But implementing a key component of "Obamacare"—even after various GOP provisions were attached that, in Snyder's words, make Michigan's plan "not generic Medicaid expansion"—is a different animal. It is staunchly opposed by most Senate Republicans, some in shock that the bill won passage in a GOP-dominated chamber.

By taking any action seen as aiding implementation of the Patient Protection and Affordable Care Act, they could face repercussions in 2014 primary elections or later in their political careers. Challengers can try to portray lawmakers' procedural vote as voting for or against the issue.

"We believe it's such an onerous law that we need to fight it every step of the way. The instinct of those senators that didn't vote for immediate effect was the correct one. We'd urge those 14 to continue to stand strong," said Scott Hagerstrom, state director for the conservative group Americans for Prosperity.

The Senate has not yet transmitted the Medicaid bill to the Republican-led House, which is waiting to send it to Snyder on Tuesday. GOP senators could hear from their leadership over the holiday weekend before deciding what to do in a private caucus meeting Tuesday.

"The focus was definitely to get House Bill 4714 up for a vote and through the chamber. We'll see what next week holds," said Amber McCann, spokesman for Senate Majority Leader Randy Richardville, R-Monroe.

Even if lawmakers decide the expansion should go on the books right away, Michigan's ability to extend coverage on day one may still be in doubt.

Michigan's approach is different than many other states accepting the Medicaid expansion made optional by a Supreme Court ruling. It includes Republican requirements that nondisabled enrollees making between 100 and 133 percent of the poverty line pay up to 5 percent of their income on medical expenses after six months. They would have to contribute up to 7 percent after getting Medicaid for four years or shop for insurance from a new marketplace where they could qualify for federal tax credits.

The initial cost-sharing provisions—along with financial incentives to lead healthy lifestyles and a plan to create individual health savings accounts—need federal approval more quickly. Snyder stopped short of saying he had received assurances that the Obama administration will OK Michigan's plan, but said his administration was open with federal officials about the bill and received "positive feedback."

If low-income adults find themselves without coverage Jan. 1, they will not have to worry about incurring tax penalties for going without insurance. The federal government has decided to not penalize residents in states that decline to expand Medicaid, so Michigan residents should not be fined for a delay out of their control.

Democrats, frustrated that Medicaid expansion was not OK'd earlier in the year, say further delays would be politically motivated and entirely unnecessary.

"A half million people's lives hang in the balance," said Senate Democratic Leader Gretchen Whitmer, D-East Lansing.