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October 14, 2014 01:00 AM

Reform Update: Tennessee, Virginia Medicaid expansion battles continue

Virgil Dickson
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    Medicaid directors from Tennessee and Virginia say they're continuing the fight to expand their programs in ways that will appease both the CMS and state legislators.

    The officials, speaking during a roundtable discussion organized by the Kaiser Family Foundation, also weighed in how access to care could be affected by the end of a provision in the Patient Protection and Affordable Care Act that boosts Medicaid reimbursement for primary-care doctors to Medicare rates.

    In Virginia, state officials have submitted four plans to its General Assembly only to get no traction, leading to a recent “aha” moment for Gov. Terry McAuliffe and his staffers, said Cindi Jones, director of the Virginia Department of Medical Assistance Services.

    “We keep forgetting it's just politics, and that's what it is at this point,” Jones said.

    Jones said she supports the idea of expansion even though she was appointed to her position in 2011 by former Virginia Gov. Bob McDonnell, a Republican. “Just focusing on the fiscal (reasons), it makes no sense not to expand,” Jones said. She added she is hopeful there will be more willingness to consider expanding Medicaid after the Nov. 4 election.

    For the past year, Tennessee leaders have entertained a variety of scenarios for expanding Medicaid, but the ghost of the state's Medicaid troubles in the 1990s has made it difficult for state lawmakers to get on board, according to TennCare Director Darin Gordon.

    In 1994, Tennessee restructured its Medicaid program and enrolled its entire Medicaid population in managed-care plans. It also extended coverage to all uninsured and uninsurable citizens regardless of income. Costs ballooned to unsustainable levels, quality of care was all over the place, and the state ultimately had start over, dramatically reducing eligibility.

    “That memory is still very fresh and we need to help people to understand why this time is different,” Gordon said.

    Based on alternative expansion waivers the CMS has approved so far, Gordon said he is confident he could craft a plan that would pass muster with the CMS. However, getting something through the state Legislature is a bigger challenge, he said.

    The state has abandoned the idea of pursuing the alternative model adopted in Arkansas, which is using federal expansion funds to help newly eligible residents buy coverage in the state's insurance exchange.

    Last month, Republican Gov. Bill Haslam hinted that the state could be ready to submit a plan to the CMS this fall.

    Gordon implied that Tennessee leaders are discussing some sort of cost-sharing scenario similar to waivers approved for Pennsylvania and Michigan. Gordon said his goal is to get some of the sicker state residents to be more proactive about their care. As many as 162,000 Tennessee residents could benefit if the state expands Medicaid.

    Meanwhile, federal funding for enhanced Medicaid reimbursement for primary care ends Dec. 31, and a recent Kaiser poll of state Medicaid directors found that 22 states won't continue the rate increase on their own. Another 14 states indicated they had not yet made a decision.

    Fifteen states, however, indicated that they would shoulder the expense of sustaining the higher rates, at least partially: Alabama, Alaska, Colorado, Connecticut, Delaware, Hawaii, Iowa, Maine, Maryland, Michigan, Mississippi, Nebraska, Nevada, New Mexico and South Carolina.

    Tennessee and Virginia will not. Gordon and Jones said the bump did not appear to entice physicians not already seeing Medicaid beneficiaries to participate in the program.

    Ohio's Medicaid expansion could end in 2015

    Medicaid expansion in Ohio could abruptly end next summer depending on how things play out with a key vote, according to University Hospitals CEO Tom Zenty.

    “In July of next year, if there is no intervention, Medicaid expansion in the state of Ohio disappears,” Zenty said during a recent panel discussion.

    At issue is how the state expanded Medicaid. After unsuccessfully attempting get his state Legislature to support expansion, Ohio Gov. John Kasich, a Republican, was able to go around them. Unlike other states, Ohio has a controlling board, which is made up of a smaller bipartisan group of state lawmakers who oversee adjustments to the state budget. Kasich got approval from that board to move forward.

    However, Medicaid spending must be reauthorized by state lawmakers as part the of the state's two-year budget cycle, which ends in June. That vote opens the window for Medicaid expansion in the state to be voided.

    No deal yet in Indiana

    Republican Indiana Gov. Mike Pence and HHS have yet to come to an agreement on the state's Medicaid expansion proposal, which was submitted in July.

    The holdup is the state's request that all participants pay monthly contributions to a health savings account, ranging from $3 to $25, or be bumped down to a more basic health plan that doesn't have dental or vision.

    The administration has previously declined to allow states to impose premiums or cost-sharing on residents with incomes below the federal poverty level.

    Follow Virgil Dickson on Twitter: @MHvdickson

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