Skip to main content
Sister Publication Links
  • ESG: THE NEW IMPERATIVE
Subscribe
  • Sign Up Free
  • Login
  • Subscribe
  • News
    • Current News
    • COVID-19
    • Providers
    • Insurance
    • Government
    • Finance
    • Technology
    • Safety & Quality
    • Transformation
    • People
    • Regional News
    • Digital Edition (Web Version)
    • Patients
    • Operations
    • Care Delivery
    • Payment
    • Midwest
    • Northeast
    • South
    • West
  • Digital Health
  • Insights
    • ACA 10 Years After
    • Best Practices
    • Special Reports
    • Innovations
  • Opinion
    • Bold Moves
    • Breaking Bias
    • Commentaries
    • Letters
    • Vital Signs Blog
    • From the Editor
  • Events & Awards
    • Awards
    • Conferences
    • Galas
    • Virtual Briefings
    • Webinars
    • Nominate/Eligibility
    • 100 Most Influential People
    • 50 Most Influential Clinical Executives
    • Best Places to Work in Healthcare
    • Excellence in Governance
    • Health Care Hall of Fame
    • Healthcare Marketing Impact Awards
    • Top 25 Emerging Leaders
    • Top 25 Innovators
    • Diversity in Healthcare
      • - Luminaries
      • - Top 25 Diversity Leaders
      • - Leaders to Watch
    • Women in Healthcare
      • - Luminaries
      • - Top 25 Women Leaders
      • - Women to Watch
    • Digital Health Transformation Summit
    • ESG: The Implementation Imperative Summit
    • Leadership Symposium
    • Social Determinants of Health Symposium
    • Women Leaders in Healthcare Conference
    • Best Places to Work Awards Gala
    • Health Care Hall of Fame Gala
    • Top 25 Diversity Leaders Gala
    • Top 25 Women Leaders Gala
    • - Hospital of the Future
    • - Value Based Care
    • - Supply Chain
    • - Hospital at Home
    • - Workplace of the Future
    • - Digital Health
    • - Future of Staffing
    • - Hospital of the Future (Fall)
  • Multimedia
    • Podcast - Beyond the Byline
    • Sponsored Podcast - Healthcare Insider
    • Video Series - The Check Up
    • Sponsored Video Series - One on One
  • Data Center
    • Data Center Home
    • Hospital Financials
    • Staffing & Compensation
    • Quality & Safety
    • Mergers & Acquisitions
    • Data Archive
    • Resource Guide: By the Numbers
    • Surveys
    • Data Points
  • MORE +
    • Contact Us
    • Advertise
    • Media Kit
    • Newsletters
    • Jobs
    • People on the Move
    • Reprints & Licensing
MENU
Breadcrumb
  1. Home
  2. Payment
October 24, 2018 01:00 AM

Medicaid expansion on the prairie: Nebraska's ballot initiative heads to the polls

Susannah Luthi
  • Tweet
  • Share
  • Share
  • Email
  • More
    Reprints Print

    The majority of Nebraskans want to expand Medicaid, and it's on their midterm ballots this November. But four years into the implementation of Medicaid expansion under Obamacare, hospitals in the Cornhusker State have tempered their expectations of how much the expansion will boost their margins.

    The Nebraska Hospital Association has pushed expansion measures for years in the Legislature and is a key supporter of the ballot measure campaign. But making more people eligible for Medicaid may not help all rural providers. It isn't clear whether enough patients in far-flung rural counties would sign up for coverage and make the difference if the state cuts reimbursement or enacts provider taxes.

    "In the Midwest, there is a pride factor," said Andy Hale of the Nebraska Hospital Association. "We just don't know how many people will enroll. If you're in a small rural county and you're a hospital, and expanded enrollment doesn't impact you, what happens if the state does a provider tax or reduces the provider reimbursement rate?"

    The accepted wisdom, particularly in rural states, is that Medicaid expansion drastically cuts uncompensated care rates and cushions often razor-thin margins for hospitals. Nebraska has fewer than 2 million residents. They live in small agricultural towns dotting the prairies or one of two major cities—Lincoln and Omaha.

    Regionally, uninsured rates are often in the double digits and in one very rural county the uninsured rate is 40%.

    Of the Nebraska Hospital Association's 90 hospitals, 64 are critical-access. On paper, the hospitals' financial outlook with expansion should fit into the narrative for other rural parts of the country, although the regional demographics vary from those in states like Kentucky or Georgia. But since Obamacare was launched, the examples of expansion state providers tell a more nuanced story, Hale said.

    The largest eligible population for Medicaid expansion—nearly 23,000 uninsured adults under Medicare age—is in Douglas County, home to Omaha, the state's largest city.

    Nebraska's Department of Health and Human Services estimated the state would likely lose some revenue from a tax on insurance premiums, as some people would likely move from private coverage to expanded Medicaid.

    In theory, expansion looks like a "windfall" for hospitals, Hale added. "But when I talk to our CFOs, that's not the case."

    By 2020, states will pay 10% of the share in expansion. Nebraska could follow the example of other states that have looked to the providers to cover that cost. That could affect hospitals' bottom lines depending on how many people enroll in Medicaid and use their coverage to get early or preventive treatment so hospitals aren't left with high uncompensated-care costs.

    Instead of a provider tax, hospitals want a tobacco tax similar to the levy Montana has proposed and California has implemented. California has also imposed a provider tax. Nebraska's share of the projected 10-year $5.5 billion expansion expense would be about $592 million, according to a September estimate from the state's Department of Health and Human Services.

    Democratic state Sen. Adam Morfield, who introduced an expansion bill to the Legislature in 2017, said it's too early to determine how the state should pay for its share. He wants to see the measure passed first.

    GOP Gov. Pete Ricketts, for years a vocal critic of expansion, is running for re-election this cycle and has not taken a public position on the ballot measure. A spokesperson did not respond to a request for comment.

    But Morfield said that in the past several years of debate Ricketts and the state's expansion opponents haven't come up with other ways to address the uninsured rates beyond additional grants to community health centers for direct primary care.

    "If you don't have money for insurance, you don't have money for direct primary care," Morfield said. "There are no other solutions. The only solutions are market controls that aren't tolerated by conservatives."

    About 78,000 uninsured Nebraskans fall under the Medicaid expansion income eligibility line of earning 138% of the federal poverty level. Of these, about 67,000 are adults who could enroll, according to data from the U.S. Census Bureau's 2016 American Community Survey and analyzed by Modern Healthcare. The average percentage of Nebraska adults who could gain coverage statewide if the initiative passes is 3.6%, although that rate changes depending on the county, from less than 1% of the local population to more than 10%.

    These numbers vary from the state's figures. Based on state economic data, Nebraska's health department estimates more than 93,000 people would enroll in Medicaid expansion over the next decade. Most reports predict more than 90,000 Nebraskans would gain coverage.

    How new Medicaid enrollments would impact hospital margins also could vary widely by county.

    Sparsely populated Keith County, where just over 8,000 people live, has an 18-bed critical-access hospital and about 900 uninsured adults under Medicare age. Fewer than 350 people would qualify for expanded Medicaid.

    Sarpy County has about 168,000 residents and two big hospitals—a 121-bed Catholic Health Initiatives hospital and 91-bed Bellevue Medical Center. Nearly 8,300 of the county's adult residents are uninsured. Nearly 2,800 would qualify for expanded Medicaid.

    The argument for bolstering rural hospitals helped to drive the state's momentum for expansion, which, according to internal polling, enjoys comfortable majority support.

    Meg Mandy, who manages the expansion campaign for the state-based group Insure the Good Life, said rural Nebraskans grasped the idea of coverage gaps and financial problems for providers.

    "So much of what drives the economy outside (Omaha and Lincoln) is agriculture-based, with no employer insurance," Mandy said. "Small-business owners can't afford to provide insurance and aren't required to. So it's just thinking through what being uninsured means outside the metropolitan and urban areas—larger out-of-pocket costs and uncompensated care, and it has put hospitals and clinics in the rural parts of the state in a bad position."

    The other argument top-of-mind for states who haven't expanded is the idea that they are subsidizing coverage in other states.

    State Sen. John McCollister, a moderate Republican who has also introduced a bill to expand, made this point earlier this month in the first of three mandatory public hearings on the ballot initiative.

    "Right now, we send hundreds of millions of our tax dollars to Washington, D.C.—money that gets spent on all sorts of things—all around this country," McCollister said. "For the last few years, we've had the opportunity to bring nearly $600 million of our tax money home every year to help Nebraskans get healthcare. Unfortunately, we've left that money on the table and watched while 33 other states brought money home to help residents in their states instead."

    The ballot initiative, backed by a coalition that includes the Nebraska Hospital Association, the state's AARP and ACLU chapters and the Center for Rural Affairs, has already survived two court challenges.

    In July, Republican state Sen. Lydia Brasch and former state legislator Mark Christensen sued the secretary of state and Insure the Good Life, claiming that the initiative's wording violated state law. A district court tossed the original lawsuit and the state Supreme Court tossed the appeal in September.

    Letter
    to the
    Editor

    Send us a letter

    Have an opinion about this story? Click here to submit a Letter to the Editor, and we may publish it in print.

    Recommended for You
    charging for advice
    How much is a MyChart message worth? It's complicated
    Most Popular
    1
    More healthcare organizations at risk of credit default, Moody's says
    2
    Centene fills out senior executive team with new president, COO
    3
    SCAN, CareOregon plan to merge into the HealthRight Group
    4
    Blue Cross Blue Shield of Michigan unveils big push that lets physicians take on risk, reap rewards
    5
    Bright Health weighs reverse stock split as delisting looms
    Sponsored Content
    Daily Finance Newsletter: Sign up to receive daily news and data that has a direct impact on the business and financing of healthcare.
    Get Newsletters

    Sign up for enewsletters and alerts to receive breaking news and in-depth coverage of healthcare events and trends, as they happen, right to your inbox.

    Subscribe Today
    MH Magazine Cover

    MH magazine offers content that sheds light on healthcare leaders’ complex choices and touch points—from strategy, governance, leadership development and finance to operations, clinical care, and marketing.

    Subscribe
    Connect with Us
    • LinkedIn
    • Twitter
    • Facebook
    • RSS

    Our Mission

    Modern Healthcare empowers industry leaders to succeed by providing unbiased reporting of the news, insights, analysis and data.

    Contact Us

    (877) 812-1581

    Email us

     

    Resources
    • Contact Us
    • Advertise with Us
    • Ad Choices Ad Choices
    • Sitemap
    Editorial Dept
    • Submission Guidelines
    • Code of Ethics
    • Awards
    • About Us
    Legal
    • Terms and Conditions
    • Privacy Policy
    • Privacy Request
    Modern Healthcare
    Copyright © 1996-2023. Crain Communications, Inc. All Rights Reserved.
    • News
      • Current News
      • COVID-19
      • Providers
      • Insurance
      • Government
      • Finance
      • Technology
      • Safety & Quality
      • Transformation
        • Patients
        • Operations
        • Care Delivery
        • Payment
      • People
      • Regional News
        • Midwest
        • Northeast
        • South
        • West
      • Digital Edition (Web Version)
    • Digital Health
    • Insights
      • ACA 10 Years After
      • Best Practices
      • Special Reports
      • Innovations
    • Opinion
      • Bold Moves
      • Breaking Bias
      • Commentaries
      • Letters
      • Vital Signs Blog
      • From the Editor
    • Events & Awards
      • Awards
        • Nominate/Eligibility
        • 100 Most Influential People
        • 50 Most Influential Clinical Executives
        • Best Places to Work in Healthcare
        • Excellence in Governance
        • Health Care Hall of Fame
        • Healthcare Marketing Impact Awards
        • Top 25 Emerging Leaders
        • Top 25 Innovators
        • Diversity in Healthcare
          • - Luminaries
          • - Top 25 Diversity Leaders
          • - Leaders to Watch
        • Women in Healthcare
          • - Luminaries
          • - Top 25 Women Leaders
          • - Women to Watch
      • Conferences
        • Digital Health Transformation Summit
        • ESG: The Implementation Imperative Summit
        • Leadership Symposium
        • Social Determinants of Health Symposium
        • Women Leaders in Healthcare Conference
      • Galas
        • Best Places to Work Awards Gala
        • Health Care Hall of Fame Gala
        • Top 25 Diversity Leaders Gala
        • Top 25 Women Leaders Gala
      • Virtual Briefings
        • - Hospital of the Future
        • - Value Based Care
        • - Supply Chain
        • - Hospital at Home
        • - Workplace of the Future
        • - Digital Health
        • - Future of Staffing
        • - Hospital of the Future (Fall)
      • Webinars
    • Multimedia
      • Podcast - Beyond the Byline
      • Sponsored Podcast - Healthcare Insider
      • Video Series - The Check Up
      • Sponsored Video Series - One on One
    • Data Center
      • Data Center Home
      • Hospital Financials
      • Staffing & Compensation
      • Quality & Safety
      • Mergers & Acquisitions
      • Data Archive
      • Resource Guide: By the Numbers
      • Surveys
      • Data Points
    • MORE +
      • Contact Us
      • Advertise
      • Media Kit
      • Newsletters
      • Jobs
      • People on the Move
      • Reprints & Licensing