December 14, 2019 01:00 AM

Year in Review: Political, legal battles continue over Medicaid expansion

The ideological battle over the Affordable Care Act’s Medicaid expansion continued to run hot in 2019, with state Republican officials pushing to impose restrictions on coverage even in states where voters mandated it.

GOP elected officials in Idaho, Nebraska and Utah delayed full implementation of voter-approved Medicaid expansion and sought to impose work requirements and other restrictions on eligibility.

But a federal judge threw out the Medicaid work requirement waivers in three other states, saying the CMS didn’t adequately consider the effect on coverage. A decision by a federal appellate court is pending. The lesson of Arkansas, where 18,000 people lost coverage in 2018 under a work requirement rule, loomed large in the legal and political arguments.

Big 3

Expansion roadblocks: GOP elected officials in Idaho, Nebraska, and Utah delayed full implementation of voter-approved Medicaid expansion and sought work requirements and other restrictions on eligibility.

Work rule challenges: U.S. District Judge James Boasberg overturned CMS approval for Medicaid work requirement waivers in Arkansas and Kentucky in March, then tossed New Hampshire’s waiver in July. A decision by a federal appellate court is pending, while five states have moved to suspend their work requirement.

Block grants on the horizon: Utah and Tennessee proposed Medicaid financing models setting per-capita caps on federal payments to the states, with the states pocketing any federal savings.

On the other hand, at least three more states considered expanding Medicaid to low-income adults. Republican lawmakers in North Carolina stymied Democratic Gov. Roy Cooper’s expansion push but say they’re open to considering it next year. Oklahoma supporters gathered enough signatures to place expansion on the ballot next November. And Georgia Republican Gov. Brian Kemp proposed a partial expansion covering those at up to 100% of the federal poverty level, even though the CMS rejected Utah’s similar proposal in July.

Beyond that, the Trump administration and GOP leaders in Tennessee and Utah are considering plans to shift Medicaid from an open-ended entitlement program to a capped federal funding model. Healthcare leaders fear cuts under this structure, though some say it could boost funding at least in the short term.

Meanwhile, state and federal efforts to tighten the eligibility redetermination process, along with a strong economy, led to a 2.2 million, or 3%, enrollment decline in Medicaid and the Children’s Health Insurance Program in 2018. Another factor may have been the administration’s proposal to penalize legal immigrants for using Medicaid, which providers say scared families away from using public health programs.