In Michigan's wake

Tina Grant said she thought lobbying for expanding Medicaid in Republican-led Michigan would be like running a marathon. Instead, it turned out to be more like a triathlon.

Grant, vice president for public policy and state advocacy at CHE Trinity Health, and other supporters of the Medicaid expansion won a big victory last week in Michigan when the GOP-controlled Senate voted 20-18 to expand Medicaid eligibility in 2014 to adults earning up to 138% of the federal poverty level, which would cover an additional 450,000 Michiganders. The Senate bill now must be reconciled with the House Medicaid expansion bill. Republican Gov. Rick Snyder supports the expansion.

The CMS still would have to approve major Medicaid changes contained in the legislation, including substantial cost-sharing by beneficiaries, which is uncertain.

“We knew it was going to be a long race, but it was more than we envisioned,” Grant said.

Under the Patient Protection and Affordable Care Act, the federal government will pay 100% of the cost for the expansion population for the first three years, and 90% after that. It's a key element of the law's coverage expansion. If all 50 states approve the expansion, it's projected that would reduce the uninsured population by

10.2 million by 2022 and provide hospitals with an additional $294 billion from 2013 to 2022, helping them provide care for the uninsured. So far, only 25 states have OK'd expansion.

The spotlight now shifts to Indiana, Ohio, New Hampshire, Pennsylvania and Tennessee, where debate continues over whether to expand for 2014. Virginia is even more iffy. New Hampshire and Virginia established commissions to study the issue. In all those states, Republican lawmakers and/or Republican governors have opposed the Medicaid expansion and the ACA, arguing that expanding Medicaid will end up imposing a heavy cost on their states. Hospitals are among the groups leading the fight to expand coverage. There is no deadline for states to adopt the expansion.

“The way we categorize states is moving forward at this time, not moving at this time and debate ongoing,” said Robin Rudowitz, associate director at the Kaiser Commission on Medicaid and the Uninsured. “So we had moved Virginia to 'not moving forward' because they passed a bill for this commission to explore, and there was really no indication that they were moving forward for January 2014.”

Jesse Cross-Call, a policy associate at the left-leaning Center for Budget and Policy Priorities, which favors Medicaid expansion, is watching New Hampshire, which also established a commission to make reform recommendations about its Medicaid program and recommend whether to expand. Cross-Call said New Hampshire has a hard deadline of October for its commission recommendations, and he lists the state as “leaning toward expansion.”

Medicaid expansion will be a big issue for the GOP-controlled Pennsylvania Legislature when it returns in the fall. Republican Gov. Tom Corbett has opposed Medicaid expansion.

In Michigan, Grant explained that the political dialogue evolved from one about expanding a government program to a discussion about how to restructure the program to lower costs and improve care. It also helped that Snyder pushed hard for expansion.

That restructuring discussion led Michigan lawmakers to include big program changes sought by conservatives that would need waiver approval from the CMS. One would establish a health savings account-like program where eligible beneficiaries would pay up to 5% of their income for cost-sharing but could reduce their premium contribution by adopting healthy behaviors. One concern, however, is many low-income people won't be able afford to pay that much and wouldn't enroll.

Some said similar provisions to put more financial responsibility on beneficiaries and offer coverage through private health plans may help advocates get Medicaid expansion passed in several other states that still are considering it. Grant said such provisions are part of the negotiations in Pennsylvania and Ohio, where Republican Gov. John Kasich supports expansion.

“We saw that was critical to the success in Michigan,” Grant said. “Similar waiver discussions happened in Iowa. Gov. Kasich in Ohio and Gov. Corbett in Pennsylvania are also looking into a waiver opportunity to develop a Medicaid program that is innovative and may be more efficient for this Medicaid population.”

Cross-Call said the Michigan decision bodes well for expansion in neighboring Ohio. Supporters have used the politically potent argument that states that choose not to expand Medicaid will essentially be sending their tax dollars to other states that do expand Medicaid.

“It's been a very effective argument for neighbors,” Cross-Call said, citing

Republican Arizona Gov. Jan Brewer's successful argument to Republican lawmakers that their state was surrounded by states that expanded Medicaid.

CHE Trinity Health has a presence in 21 states, of which 11 have chosen to expand Medicaid. Of the 10 that have chosen not to move forward at this time, Grant said she's most optimistic about Ohio, Pennsylvania, Indiana and Idaho.

CHE Trinity will continue to rely on the health system's employees to push their states to expand Medicaid. In Michigan—where the system has 12 hospitals and 28,000 employees—Trinity employees attended lawmakers' town hall meetings and sent more than 3,000 e-mails to lawmakers voicing support for the expansion.

“There is so much collective strength at the grass-roots level,” Grant said.

Follow Jessica Zigmond on Twitter: @MHjzigmond