Bipartisan efforts continue in three states to expand Medicaid to low-income adults, as the clock runs down on their legislative sessions. But expansion supporters, including hospital and business groups, face tough fights against conservatives, spearheaded by an advocacy group backed by the billionaire Koch brothers, who oppose anything associated with the Affordable Care Act.
The possibility of expansion is still alive in Alaska, Florida and Montana. An effort to expand Medicaid in Nebraska ended when lawmakers there voted 28-16 on Wednesday to send expansion legislation to the bottom of their agenda, making it unlikely it will be debated again this year.
On Thursday, Montana's Republican-controlled House voted 54-46 to approve a Medicaid expansion bill that has already passed the GOP-controlled state Senate and has the support of Democratic Gov. Steve Bullock. The bill only reached the House floor after a bipartisan group of lawmakers thwarted attempts by some House Republicans to use a procedural process to stop the bill from being considered. An estimated 70,000 people would become eligible for coverage if Montana expanded Medicaid to adults with incomes up to 138% of the federal poverty level.
The proposed bill would require co-pays and premiums for the new beneficiaries, though the details of those payments were not spelled out in the bill. Participants also would be offered assistance to either find employment or a better-paying job. The plan would require federal approval as a Medicaid waiver program.
In Alaska, the state's House Finance Committee agenda was cleared by its chair so the lawmakers could study House Bill 148, which focuses both on Medicaid expansion and reforms of the state's current Medicaid program. Lawmakers questioned the potential economic benefits of expansion. About 42,000 Alaskans would be eligible under Medicaid if it were expanded.
In Florida, after Republican Gov. Rick Scott reversed his position and now opposes expansion, Republican leaders in the state Senate said a Medicaid expansion bill would cover an estimated 800,000 additional adults. That plan also would need federal waiver approval because it includes premiums, work requirements and a six-month termination of benefits for people who don't pay their premiums.
On Tuesday, Florida's Senate Health Policy Committee postponed voting on confirmation of Scott's nominee for state surgeon general, Dr. John Armstrong, after he repeatedly declined to give his opinion on Medicaid expansion. The more conservative GOP-controlled Florida House has passed a budget that does not include Medicaid expansion.
As of Thursday, Republican leaders in the Florida House and Senate had yet to start talks to reconcile their dueling budget bills, according to Katie Betta, a spokeswoman for state Senate President Andy Gardiner. The two chambers have until May 1, the last day of the legislative session, to reach a compromise. If they can't, they will need to hold a special session. Florida's next fiscal year starts July 1. There is about a $4 billion funding gap between the Senate and House budgets, which largely has to do with whether the state accepts Medicaid expansion dollars.
Hanging over the Medicaid expansion debate is an impasse between the Scott administration and HHS over whether to renew federal funding for the state's low-income pool to fund hospitals serving uninsured and low-income patients. Scott has said the Obama administration's refusal so far to renew the funding demonstrates that the federal government can't be counted on to continue Medicaid expansion funding under the Affordable Care Act.
With time running out in the current legislative cycles in the three states, some observers predict those expansion efforts will fail this year. “At this point, (another state expanding) probably won't happen this year just because the legislative sessions in most of these states are so time-limited,” said Ed Haislmaier, a health policy expert at the conservative Heritage Foundation, which opposes the ACA. “I'm sure this will be brought up again next year.”
Haislmaier defended the arguments made by Scott and other Republicans opposed to Medicaid expansion, agreeing that the federal government can't be trusted to continue funding the expansion.
There is no precedent for HHS or Congress to discontinue federal funding for any state's Medicaid program. But Congress rolled back increases in the federal match rate that were implemented during economic recessions in 2001, 2004 and 2009 as temporary financial supports to states, according to the Kaiser Family Foundation.
Deborah Bachrach, a partner at Manatt and former Medicaid director for New York state, noted, however, that under the ACA, it would take action by Congress to drop the federal match below 90% for the expansion population.
Republican opponents of Medicaid expansion also cite President Barack Obama's fiscal 2013 budget, which included a suggestion to blend matching rates for Medicaid and the Children's Health Insurance Program, starting in 2017. Right now, the federal government pays higher match rates for some Medicaid activities than others. For instance, it's now paying a 90% federal match rate for states to upgrade and maintain their Medicaid health information-technology systems. If Obama's 2013 proposal had become law, the CMS would have paid one flat rate for anything involving Medicaid or CHIP.
Republicans also may be thinking about their own plans for sharply cutting Medicaid spending and turning Medicaid into state block grants if they win the White House and hold on to Congress in next year's elections. Such plans are included in the budgets recently passed by the GOP-controlled House and Senate.
“The more general fear is that changes to the Medicaid program are inevitable,” said Yevgeniy Feyman, a fellow at the conservative Manhattan Institute. “The need for entitlement reform will necessitate changes at the federal level. And reductions in the match rate are one way of doing so.”
