Ohio’s Medicaid expansion is in jeopardy

Today is the gubernatorial primary for the state of Ohio. The state has had one of the most successful Medicaid expansions in the country in terms of the number of people who became newly eligible. Regardless of who wins this primary, Medicaid in Ohio is bound to change and how it changes will be determined in large part by this election and the general election in November.

Governor Kasich took a risk when he defied his state legislature and passed Medicaid expansion in 2013 using a procedural rule in the state that allows the governor to bypass the legislature. Not only did he defend the policy at the state level despite many attempts to cut or eliminate the program by the legislature, he ran on the successes of the Medicaid program when running for president. His appeal to the moderate sides of the Republican party through his support of Medicaid expansion has given him the name of a compassionate conservative or a moderate in support of government programs.

However, his state has submitted a work requirement waiver proposal that goes beyond any proposal that has been approved to date. Kasich himself is term limited and will not be running for re-election in November. The two main candidates for governor in the state have taken a hard stance against the Medicaid expansion. Baring the election of a Democrat in office in November, it appears that the Medicaid expansion in Ohio is on the cusp to dramatically change.

The lead Republican candidate for governor, Mike DeWine, is the current Attorney General and has previously served in the House and Senate as well as lieutenant governor. DeWine has been relatively quiet on his Medicaid expansion stance. He has repeated that he would ask the Trump Administration for waivers. He has not specified exactly what these waivers would include and provide any additional details about his plan. During a debate in April he responded to pressure to answer whether he would keep the Medicaid expansion with, “Mary, it will not exist as we know it today. It can’t, and it was your administration that took it.” He then proceeded to artfully redirect the debate to his challenger’s performance as lieutenant governor. It is likely that his plan is to impose work requirements, lifetime limits, or other restrictive policies outlined by the Trump administration that would limit the number of people in the Medicaid program. During the primary he is pushed to have a position against the Medicaid expansion but he is caught with the fact that he will likely have to run on a more moderate position surrounding health care in the general election. This means he’s trying as much as possible to not provide too many details on his plan at this time. Advocates in favor and against Medicaid are pushing to get him on the record so they can run against him on either side either in the general election or the primary, respectively.

The challenger, Mary Taylor, is the current lieutenant governor and has run on a platform of repealing the Medicaid expansion. During the campaign she has insisted that the expansion has been bad for Ohio and that she would get rid of the expansion all together. She has not always had a negative view of the Medicaid expansion, however. In serving as the lieutenant governor she has been supportive of actions of the Kasich administration including the decision to expand. When Kasich was running for President, she supported his decision to expand Medicaid in an op-ed she penned. Taylor is running behind DeWine in the latest polling but has been surging in recent months. Her political strategy is likely to run to the right of DeWine and in the general trust that the Republican electorate will turn out.

The work requirement proposal submitted by Kasich in recent weeks goes beyond any proposal submitted thus far. It is hard to imagine how DeWine could envision a waiver program that is more conservative than the one Ohio has pending. The proposal would require Medicaid beneficiaries to meet an 80 hour monthly work requirement. If beneficiaries fail to do so they will be required to work without salary to pay for the cost of their Medicaid coverage. Not only does this requirement present serious concerns for labor laws, from a health policy perspective it will incentivize people to use less care. We already know that when low-income people are charged cost sharing for their health care services that they are less likely to use health care. We also know that this is detrimental to their health. Similarly, if a person knows that they will have to work for free if they use health care services they are likely to not use needed health services. This could cause the low-income population to have worse health outcomes than if they had no insurance or than if their Medicaid was not tied to work. One of the main arguments that the Trump administration has made surrounding work requirements in the Medicaid program is that work improves ones health. From the research that was proven in the seminal RAND health insurance experiment, we know with certainty that barriers to care are detrimental to the health of low-income people. Certainly, working for no pay would be an equivocal disincentive to getting care as a few dollars in copayments had been in the RAND experiment.

Meanwhile the Democratic candidates for governor in Ohio have not run to limit Medicaid either through a waiver or ending the Medicaid expansion. Richard Cordray, the former director of the Consumer Financial Protection Bureau and former Ohio Attorney General is leading a crowded field of candidates. His main competitor, former Congressman Dennis Kucinich, is about 15 points behind in the polls. Both candidates have campaigned on protecting the Medicaid expansion. They have also extended their campaigns to focus on ways to ensure more Ohioans have access to health insurance and strengthening the Medicaid program.

No matter what happens in the gubernatorial election the Medicaid program is likely to change before Kasich leaves office. Ohio is a dynamic health care market with unique and difficult challenges including the opioid crisis. Today’s election will present an opportunity for voters to make their perceptions of the Medicaid program known to the elites.

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Should Medicaid Be the Backstop for High Cost Drugs?

This week the LA Times ran a story about the high cost Medicaid patient in California that was often used to describe the role of Medicaid in providing life saving treatment that people would not be able to afford without the Medicaid program.

The boy was estimated to cost the state’s Medicaid program, known as Medi-Cal, an estimated $21 million due to the high-costs of prescription drugs needed for his hemophilia.

Approximately 20,000 patients in the United States suffer from hemophilia, needing an estimated $4.6 billion in drugs to prevent complications due to lack of an ability to clot blood. There is no cure for hemophilia and no cheaper substitute for these rare and most costly drugs. Medicaid covers one in three people living with the disease.

Medicaid has historically played a vital role in providing treatment for high-cost patients who are often left without any other alternative source of payment for their health care. The AIDS crisis of the 1980s and 1990s is a good example of the role Medicaid played.

But whether Medicaid should be the only option shouldering the cost of complex and high cost patients is another story. Rare diseases have complex drug policy associated with the government trying to incentivize drug manufacturers to invest in these markets without losing the profit motive. Since rare diseases are often genetic or involve comical diseases that primarily impact certain often stigmatized populations (low-income individuals, certain minorities, etc.) government involvement is often necessary in order to ensure equity. Similarly, since Medicaid often already provides health care for these populations, Medicaid has become almost the de-facto primary funder for many rare diseases. Medicaid should cover individuals that have no other access to care and are among the most fragile populations in our society. Medicaid should be the safety net fro many people who need care. But that does not mean that the government should depend on the Medicaid program to provide that care without budgetary increases or additional budget monitoring when new technologies are introduced to help people with rare diseases. If Medicaid didn’t cover these populations already, there would likely be a new program created and a new funding stream established to fund the populations effected. This is what happened eventually in the AIDS crisis and at several other points in the past with rare or complicated diseases or treatments such as End Stage Renal Disease. These essentially separate funding streams allow for dedicated funding and when Medicaid experiences cuts in spending, these special populations would be protected. On the reverse end of the spectrum, if Medicaid is not seeing being in a large mandatory spending program protects cuts and the special programs. At what time that it is beneficial to place a more niche and targeted program within a larger mandated benefit program that is under threat of budget reductions is difficult to tell. This depends largely on the political climate and the economic conditions of the government at the time. It also varies based on the public perception of the disease group. If a disease group has positive favorability among the public, it is more likely to receive political protection and increased funding. However, if the disease group is stigmatized it will likely see less protection and become a target for cuts rather than a protected funding source.

Medicaid changes in Idaho

idahoMuch has been made about the Idaho plan to allow health plans to be sold that do not meet requirements set out by the Affordable Care Act. The plan has been raised by Idaho’s governor who is up for reelection in 2018 and trumpeting this plan as a part of his reelection bid. But in the House, there was an attempt this week to make this policy permanent. The House bill, deemed, “The UnAffordable Care Act” led by Rep. Bryan Zollinger (R-Idaho Falls) would make allowing plans that don’t meet the minimum criteria state law and would make significant changes to the state’s Medicaid program.

The bill would institute work requirements for the existing Medicaid population and would set a lifetime limit of five years for certain eligibility groups. While it exempted children and pregnant women it would set limits on certain disabled populations. This would in essence take away coverage for some of the most vulnerable people in society. The Centers for Medicare and Medicaid Services has not yet issued guidance on whether it would approve a state’s plan to put a lifetime limit on Medicaid benefits. The Administration is going to have a harder time proving that lifetime limits meet the goals of the Medicaid program than the argument made to further work requirements. Additionally, these requirements were proposed by a state that has not yet expanded Medicaid. This means that the work requirements and lifetime limits will be imposed on a population that was previously eligible for Medicaid and has long been determined to be the “deserving poor.”

This proposal comes at the same time as activists are working to collect signatures to put Medicaid expansion up for vote in the November ballot, the legislature has proposed an alternative bill that would reduce the burden of the people in the insurance gap and the governor has instituted an executive order that would allow insurers to sell plans that do not meet standards set by the Affordable Care Act.

Zollinger’s bill did not pass through committee. However, this does not end the potential changes that Idaho will likely see as there is clearly a debate in the legislature, governor’s office, and public about the future of the program.

Medicaid Work Requirements Illustrate our Nation’s Poor Policy Making for Former Felons

The criminal justice system is meant to be a system that finds justice, gives an appropriate punishment, and once the punishment is fulfilled, helps people convicted of crimes contribute to society. Prison time has the dual purpose of punishment and rehabilitation. Yet, more and more people who have been convicted of crimes and served their time are being denied basic entitlements and rights of citizenship in the United States.

For many, the right to vote is the first thing that comes to mind for rights that are reduced after serving time. However, the barriers placed on the ability to work present a more subtle and accepted form of America’s inability to bring former felons back into society. Now, as many states look to tie work to the ability to gain health insurance, the problems that these barriers present are becoming even greater in importance.

Many have heard of the effort to “ban the box” or remove the question on many job applications asking whether a person has been convicted of a crime. This effort has had moderate success in ensuring people that have been convicted of a crime have the opportunity to seek employment. But the success has been localized and the practice is still persistent creating a barrier to employment for many former felons.

The administration and leaders in the states advocating for this change would argue that they provide many opportunities to people other than getting a job. People can get involved in community service or do job training activities under these waiver plans. However, if anyone has become involved in community service over the last decade can attest, there are often significant barriers to prevent people from these opportunities as well. Nearly all volunteers opportunities that may involve children present require that volunteers go through a background check process. More and more other community service related activities are requiring similar additional steps in order to shield themselves from liability and keep their costumers safe. In a perfect world there would be community service opportunities available to all people that would like to contribute to the betterment of their community. However, these opportunities are not available to everyone.

Those in favor of this policy may continue to argue that people with a history that includes interactions with the criminal justice system may still have an avenue to obtain Medicaid coverage. It is true that there are other avenues that a person could take to fulfill the requirement. For instance, a person could enroll in a job-training course. This would fulfill the requirement, yet a person can only take so may of these courses. If they are prohibited from getting a majority of jobs in the area, what value are these job-training programs?

People that have had interaction with the criminal justice system have higher rates of opioid addiction. Kentucky and several other states that have debated instituting the work requirement provision have been ground zero in the opioid epidemic. While the Administration was able to see the problem of requiring people who are addicted to opioids to work when jobs in the area often require drug tests. Further, Medicaid is a main payer for opioid addiction services. Seeing this problem of creating a work requirement for the population would essentially exacerbate the opioid problem, the administration made an exception for people who are currently in treatment. As had been mentioned elsewhere, opioid treatment programs in many parts of the country have wait lists and additional barriers to participation. Therefore, it is conceivable that someone who is suffering from addiction may not be able to get a job or receive treatment and would in turn lose their Medicaid, the only way many are able to pay for treatment since Medicaid is the primary payer for opioid addiction services. While the exception for opioid treatment was an important step to ensure that people suffering from opioid addiction do not lose their access to a way of treating their addiction, the problem remains. There will still be many people who continue to suffer from addiction and do not receive the help that they need. The Trump Administration’s opioid task force and many other on both sides of the isle have recognized the important role Medicaid plays in addressing the opioid epidemic. Yet, the proposal out of Kentucky and the guidance outlined by the Centers for Medicare and Medicaid Services (CMS) has ignored this critical role in curtailing the epidemic. Ignoring the challenges to accessing treatment has the potential of making the opioid epidemic even worse.

Kentucky and other states that are contemplating the work requirement options outlined by CMS must make an effort to ensure that either job or community service opportunities are available to formerly imprisoned individuals. States won’t receive help for paying for these services from the Trump administration. The guidance outlined that states could not use federal funds from CMS to pay for these activities. This is consistent with other federal policy related to the use in Medicaid funds and CMS likely made the correct judgment when determining that Medicaid funds could not be used for these activities. However, CMS made the wrong decision when not requiring that the state make these opportunities available and partnering with other parts of the federal government to provide the financial resources to ensure that states have the ability to require additional barriers to beneficiaries. To be clear, the requirement that beneficiaries work at all is both legally tenuous and morally wrong. But if the administration is going to allow states to make requirements of their citizens, it is the obligation of the federal government to protect those who may be unable to protect themselves. While Medicaid is a jointly funded state and federal program largely administered at the state level, the beneficiaries are beneficiaries of both the state and the federal government. A federal floor is necessary to protect beneficiaries from a state government that is focused on reducing benefits or providing subpar access to health resources. A state has an incentive to maintain Medicaid programs due to the large amount of federal funds that flow into the state through Medicaid, stimulating the health care economies of states. The federal government has a responsibility to the taxpayers as well as to beneficiaries to ensure that the state governments are meeting the intended use of these federal funds. Medicaid funds have the purpose of improving the health and financial well being of the intended beneficiaries. Creating barriers and preventing whole groups of people who the law was intended to make eligible for health care goes against the mission of both states and the federal government to protect beneficiaries and provide high quality improved health. The law intended to be available for people who are unable to get coverage because of lack of employer based health insurance. It has been widely known that former convicted felons have had a higher rate of uninsurance due to difficulties getting jobs after prison.

It is the responsibility of the state to ensure that if they put a barrier between a person and a benefit that any individual can reasonably overcome the barrier. In the case of work requirements, the barrier is often too high for people who have a history involving the criminal justice system.

LePage is making a clearly false argument about Medicaid expansion

In November Maine voters approved a proposition to expand Medicaid to residents making under 133% of the federal poverty level. This expansion has been supported by the state legislature but obstructed by the Governor since the Supreme Court made the Medicaid expansion a state’s decision. The Governor has claimed that he requires the legislature to act before submitting an application for expansion, requiring the legislature to take up the debate.

Last month it was reported that the state legislature plans to begin debate on Wednesday on the funding of Medicaid expansion. At the bottom of the article it noted that Governor LePage “claims expansion’s $54 million price tag would balloon hospital debt and divert money from the elderly, disabled and children.” Both of these arguments have been proven false time and again but what is unique is that few politicians have made the argument that hospital debt would increase as a result of the Medicaid expansion. The argument that Medicaid reduces uncompensated care costs is often used as a reason for states to expand Medicaid. Right now hospitals in non-expansion serve many patients who are uninsured. These hospitals will often cover the cost of these services at a loss. Research has shown that reimbursing for these services on it’s own reduces uncompensated care. What recent argument have tried to suggest is that the loss of uncompensated care may hurt the potential gains that some hospitals see. These gains come from two sources: first the DSH payments and second the non-profit status.

Hospitals today are unlike many other industries because they rely heavily on a system of not for profit entities. In order to maintain that not for profit status, hospitals must meet various restrictions set by states. One of these restrictions is how much uncompensated care a hospital provides. Some states factor more heavily the acceptance of Medicaid patients. These policies are based off of a prior world where uncompensated care was more common because of the higher uninsurance rate. Hospitals often take a loss with treating Medicaid patients in comparison to privately insured patience and while it makes sense that taking a small loss would be better than taking zero dollars a growing sentiment among hospital managers is that taking the larger loss may be better for hospitals bottom lines. That way the hospital could maintain their non-profit status and qualify for additional DSH payments. So there is a plausible reason that certain hospitals that would be on the cusp of losing non-profit status may face financial risk and that if the DSH reductions ever are implemented hospitals that rely on DSH payments may see financial reductions. However, Congress has been pushing the date of the DSH reductions back since they were originally meant to be implemented in 2014 and all indications suggest that this date will be pushed back further in future funding bills. Additionally, as mentioned previously, the determination of non-profit status of hospitals was set by many states in an era that did not envision the Medicaid expansion or the coverage expansions of the Affordable Care Act. These laws need to be updated regardless of whether a state were to expand Medicaid or not in order to ensure that tax law is being directed to providing exempt status to the facilities that are providing service to the community.

LePage’s second argument that Medicaid expansion would divert resources and attention away from the elderly and disabled beneficiaries is a long held talking point by the right. This point also is not ground in fact, in fact it has been suggested to have the opposite effect in many states. There is some evidence that states that expanded Medicaid have seen improved funding available to existing long-term care programs and other traditional Medicaid programs. While LePage’s argument would make sense if there were a limited number of resources available, as under a block grant scenario where the block grants don’t account for differences in the type of populations that the Medicaid program serves (none of the current block grant proposals suggest this). However, states that have more generous social service programs for low-income people are also states that have better economic conditions in part because low-income people drive economic activity when supported by these programs. Medicaid expansion has been shown to be a driver of economic activity in the state leading to a potential for greater resources available to existing state programs, including programs for the disabled. LePage’s argument is based on a very crude understanding of how state budget decisions are made.

This argument induces a fear of cutting programs that help people with disabilities and attempts to pit disability groups against supporters of expansion. However, as has been evident in the repeal efforts of 2017, disability groups support the tenants of Medicaid expansion and understand that the expansion of Medicaid can have positive effects for existing Medicaid programs. When the coalition of Medicaid supporters includes a greater number of interests, often in state legislatures or when there is greater attention paid to the issue, an attack on Medicaid mobilizes all of the interests, rather than a group supporting just one portion of the program threatened by cuts. Third rail programs are defined as such not because they can be chipped away at the sides but because they are electric the whole length of the rail. And while Medicaid has not historically been a third rail program, the recent Medicaid expansion vote in Maine coupled with the repeal debate is starting to show that Medicaid has a political constituency and that political constituency is not simply confusing the names of the programs. It is becoming a third rail program which means that it will become difficult for politicians to argue for any particular Medicaid cuts without seeing the weight of the entire interest group. It is unclear whether this argument has yielded the intended effect of separating and pitting groups against each other in any state. Therefore, not only is this talking point inaccurate, it appears to be ineffective.

LePage’s efforts to stop the Medicaid expansion referendum in his state were expected and aren’t expected to be successful. However, the talking points that he is trying to make and the rhetoric in opposition of Medicaid will continue beyond LePage and his term. Advocates should work to dispel these talking points and should ensure that the public is not misinformed about the program. Hospitals that have seen increased revenue and doctors that see fewer patients without insurance should speak to these improvements. As the Medicaid expansion becomes more common and the effect of insurance coverage is something that becomes well understood, it is going to become more difficult to tell the story of the importance of these programs. Advocates must remind people of the importance of these programs through personal stories that center on the services that Medicaid provides not the life before and after the Affordable Care Act. These stories will be similar to countless stories about the role Medicaid plays in the long-term care setting and will be difficult to gain attention. Yet, just because something is known in health care does not mean it won’t surprise people when reported.

Why Maine’s Medicaid expansion proposition could be big news for other states

This Tuesday, Maine voters will be deciding whether the state that has continued to vote for Medicaid expansion in their legislature will take the unusual avenue of approving Medicaid expansion through a proposition. The referenda would make Maine the first state to expand Medicaid not through the governor or state legislature’s authority.

The legislation is currently polling well with the last publicly released poll putting the referendum at 69 percent. Although it’s important to note that referendum, especially propositions that involve state spending, as this one would, tend to lose support closer to Election Day. Further, because this is an off year election with few major statewide races on the ballot, turnout is likely to be lower than Presidential or Congressional years. Typically, the voter base in low turnout elections favors conservatives.

Governor Paul LaPage who helped form a group in opposition to the measure heavily opposes this particular ballot measure. However, currently the spending by those in favor of the proposition exceeds those opposed to the ballot measure. Additionally, the groups in support of the ballot measure have instituted grassroots measures of knocking doors and passing out voting literature in and around the Portland region.

Several states have already initiated signature gathering process to include Medicaid expansion on the ballot in future elections. Utahans and Idahoans are are currently collecting signatures to include Medicaid expansion on the 2018 statewide ballot.

In 2014 Wisconsin 19 of the 72 counties included a resolution to expand Medicaid and the proposal won by large majorities across the state, even in counties that went heavily for Republican Governor Scott Walker. The referendum overall received 74 percent statewide. The legislature and the governor uniformly rejected the non-binding ballot initiative and no further action has been taken on Medicaid expansion in the state.

There is concern that the same can be said about the Maine initiative. Unlike in many Western states where propositions are written into the state constitutions, in Maine the governor has the ability to declare that there is not enough funding available and the initiative must go back to the legislature for approval within 45 days of the start of the session. This ballot question requires that the state submit a plan to the US Department of Health and Human Services within 90 days of the initiative taking effect. However, Maine has a history of slow walking initiatives in the state and failing to implement them all together. This particular case may be different because the legislature has voted and approved expansion about six times only to be blocked by the governor’s veto. At the same time, the legislature and Presidential administration has changed since these votes and the legislature never had the votes to override a veto. Taken together, the process of Maine expanding Medicaid could take a significant amount of time if the Governor and state legislature so decides.

Puerto Rico Medicaid funding in House CHIP Bill

The House released and voted on an amended version of their CHIP reauthorization bill this week. This bill primarily changed the way that the CHIP program is paid for by the federal government by increasing the premiums for high income earning Medicare beneficiaries. The bill has come under criticism for including a large number of partisan proposals that primarily focused on repealing various provisions of the Affordable Care Act. One provision of this bill that has largely escaped critique is the additional funding for Puerto Rico following the hurricanes that have devastated the island.

As I have discussed previously in this blog, Puerto Rico’s Medicaid program is block granted, meaning that they are limited in the amount of federal funds they receive. This makes events such as the hurricanes especially difficult. More people rely on the Medicaid program during an emergency or time of economic distress. The program is counter cyclical in that it acts as a safety net to ensure that people who are facing financial downfall do not experience greater distress under periods of larger financial distress. It blunts the pain.

The plan passed by the House GOP provides $1 billion toward the Medicaid program in Puerto Rico and the Virgin Islands. The two islands’ programs have been financially strained under the weight of more people requiring health services and more people losing their insurance coverage and qualifying for Medicaid. The finances would not provide sustained funding but would act as a band-aide. One requirement of the funding is that they would only be able to access a portion of the funds if they meet certain anti-fraud measures. This is interesting because such provisions were not included in similar funding bills made available to Florida and Texas following their hurricanes. Additionally, the provision only applies to the Medicaid program when there is likely significant fraud in both the private insurance market and the Medicare Managed Care program in the territory. Yet only the Medicaid program is called out for reduction in fraud. True that Medicare and the fraud control for the program is run at the federal level and the bill is related to Medicaid funding. Both of these points are good reasons why fraud prevention programs and targets would not be included in this bill. However, the purpose of this bill is to give the territory disaster relief, not to continue the basic functions of the Medicaid program in the territory. Therefore, an equal argument can be made that the purpose of the bill is not to enact fraud control thus requiring Puerto Rico to do so also violates the germaneness of the bill.

This bill unlike other forms of previous legislation funds the Medicaid programs for both Puerto Rico and the Virgin Islands. The Virgin Islands’ Medicaid increase is pegged to Puerto Rico’s spending on a per capita basis. Therefore, if Puerto Rico spends $100 per a person in Puerto Rico the Virgin Islands will also receive $100 per person. This does not take into account the health needs of the Virgin Islands or the difference between the income or other population differences of the two territories. The Virgin Islands also experienced the brunt of the hurricanes and the island is in need of disaster relief, however this shouldn’t necessarily be tied to Puerto Rico’s spending, it should be additive in a manner that makes the most sense for both of the islands.

Additionally, Reuters wrote about the latest request from the territory for a greater infusion of funds for the Medicaid program over the next 5 years. Definitely worth a read to better understand the dire situation on the island.