WellCommons

Lawrence call center expected to add positions to handle insurance exchange calls.

Four states that have snubbed the federal health law by defaulting to the federal government to build new online insurance marketplaces and not agreeing to expand Medicaid are getting new jobs at call centers that will help consumers understand their new coverage options this fall. Kansas is one of the four states.

Up to 9,000 jobs are expected to be created at call centers to support the new federally run marketplaces. A U.S. Department of Health and Human Services spokeswoman said some of them will be added to existing Medicare call centers in Phoenix, Chester, Va., Lawrence, Kan., and Tampa, Fla. — all states with Republican leaders who oppose the law.

A fifth center in Coralville, Iowa and a sixth in Corbin, Ky., will also be expanded, she said. Plans are still being finalized for other locations, she said.

Of those states, only Kentucky is setting up its own online insurance marketplace that will help people shop for individual or small employer coverage. Iowa, will run its exchange in partnership with the federal government. The other states are relying entirely on the federal government.

Of the six states getting call centers, only Kentucky has committed to expanding Medicaid in 2014, even though governors in Florida and Arizona say they support it. So far, 22 states have agreed to expand Medicaid.

The jobs are through Vangent, a General Dynamics Information Technology subsidiary, which was awarded a $530 million one-year contract by the federal government to set up call centers to answer inquiries related to the insurance marketplaces in 34 states where they will be run in whole or part by the federal government.

The government estimates that next October, when the marketplaces go live, the call centers will be open seven days of the week, 24 hours a day, handling 6.1 million phone calls and 23,000 e-mails. The contract could be renewed for up to nine more years, making it potentially worth more than $5 billion.

States running their own marketplaces will have their own call centers.

The marketplaces are expected to expand health coverage to about 27 million people by 2016. Under the federal contract awarded to Fairfax, Va.-based Vangent, the company will also field inquiries about Medicare, Medicare Advantage and “other relevant programs,” the award announcement stated.

→ More info on health reform and the coming Kansas health insurance exchange on khi.org.

Gov. Sam Brownback talking with Anna Lambertson of the Kansas Medicaid Access Coalition last month at the Statehouse. The coalition delivered a petition with more than 2,700 signatures urging expansion of the state Medicaid program, which currently has among the tightest restrictions in the nation. by KHI News Service

Advocates pushing Kansas officials to expand Medicaid acknowledge it is unlikely they will achieve their goal this year.

But they said they remain hopeful they can convince Gov. Sam Brownback and legislators next year to make more Kansans eligible for the program.

“If it’s not going to happen the first year, we’ll continue to build grassroots support. We’re not giving up,” said Anna Lambertson, director of the Kansas Health Consumer Coalition, one of the groups pushing for expansion.

Medicaid, known in Kansas as KanCare, currently provides medical and long-term living assistance services for about 380,000 poor, disabled and elderly Kansans. Expansion could increase enrollment in the program by as many as 240,000, according to various projections.

The federal Affordable Care Act initially required states to expand Medicaid eligibility. However, the U.S. Supreme Court decision that upheld the law made expansion optional for states.

Expansion would have a bigger impact in Kansas than in many other states. That’s because the state’s current eligibility criteria exclude all but the poorest adults. Only those with children and incomes less than 32 percent of the federal poverty level — about $6,000 a year for a family of four — can qualify. Implementing expansion would mean that adults in that same family of four could make more than $31,000 a year and qualify.

The Brownback administration has estimated that expanding eligibility for the $3.2 billion program would cost the state an additional $600 million over 10 years.

Door still open

Whenever asked about expansion, Brownback says things that suggest he’s more likely to say “no” than “yes” to it. But advocates said they remain encouraged by the fact he hasn’t rejected the idea.

“If he’s really looking at the options with an open mind — as he himself has said he’s doing — then I see him taking his time (to decide) as beneficial,” Lambertson said. “I’d rather that he take his time than just say ‘no’.”

Last week, Brownback again expressed doubts that the federal government could afford to keep its promise to cover all the costs of expansion for the first three years and no less than 90 percent thereafter. Despite his misgivings, he said, he continues to have “active conversations” with expansion advocates and legislators on the topic.

“It’s in the legislative process,” Brownback said. “Expansion would have to be addressed by the Legislature. They would have to budget it.”

Brownback’s requirement that legislators budget for it before he would sign off on it has advocates convinced a decision won’t be made this year.

Budget negotiations

Members of the House-Senate conference committee negotiating a final version of the fiscal 2014-15 budgets are scheduled to return to the bargaining table early next month when the Legislature returns to Topeka for what leaders hope will be a brief wrap-up session.

→ Continue reading on khi.org.

The first personally meaningful information many Americans receive about the Affordable Care Act could come as they sit down with tax preparers. H&R Block is routinely telling its clients about subsidies or tax penalties that may lay in store for them while preparing their customers 2013 tax returns. by KHI News Service

With the filing deadline approaching, the nation’s largest tax preparation company is letting its customers know how they are likely to be affected by the Affordable Care Act.

“After the ACA was upheld by the Supreme Court in 2011, we did some focus groups and some surveys to try and measure the public’s understanding of what all is in the ACA,” said Meg Sutton, senior advisor for tax and health care services at H&R Block. “It became pretty clear that there needed to be a process for educating our clients.”

Sutton called the 2010 federal health reform law the “biggest tax-code change in the past 20 years.”

The company’s tax preparers, she said, have been calling their customers’ attention to the ACA’s penalties for not having health insurance and to the subsidies that will be available to low- and modest-income families.

The information also is available on an H&R Block website.

“Client reaction has been very positive,” Sutton said.

The company’s surveys, she said, had found that 77 percent of its clientele didn’t realize their 2013 tax returns would be used to determine their eligibility for health insurance subsidies and that 44 percent of those between ages 18 and 34 were unaware of the penalties for being uninsured.

Sutton said the company’s tax preparers do not tell their customers to buy - or not to buy – health insurance. Instead, she said, customers are “informed of their options” based on the information in their 2013 tax returns.

The ACA’s mandate that almost all Americans either have health insurance or pay a penalty takes effect Jan. 1, 2014.

Marvin Lawton has been a tax preparer at the H&R Block office in Topeka for the past eight years.

“I’ve found there to be quite a cross section in the way people react – all the way from being OK with it to being dismayed by it,” he said. “Some are OK with it because they already have insurance and won’t be affected by it, some are bewildered over how they’re going to afford it and some wonder why they have to pay a penalty if everybody in their family is healthy."

Most of his customers with little or no health insurance have seemed pleased to hear about the subsidies, he said.

“I’ve had a lot of people who used to have insurance through their job but ended up getting laid off in the past year,” he said. “They know how expensive health insurance is. So when I tell them about penalties, they say ‘But I can’t afford it.’ Then, when I tell them about the subsidies and how they’ll be able to buy it through the exchange and be part of a larger pool, they’re OK with it. They say they’re OK with it if it’s affordable. And I say that’s the intent, that’s why it’s called the Affordable Care Act.”

H&R Block customers have the option of signing up for email alerts on changes in the new health reform law.

Sutton said, H&R Block appears to be the only national tax preparation firm helping its customers predict the law’s effect on their 2014 taxes.

Surveys have shown that about 60 percent of the nation’s taxpayers use tax preparation companies. H&R Block accounts for almost 20 percent of the tax-preparation market.

Kansas Health Consumer Coalition Executive Director Anna Lambertson said she welcomed the company’s initiative.

“I think it’s great,” Lambertson said. “I give them high marks.”

The coalition, she said, has been looking for ways to launch a similar informational campaign in Kansas.

“We can’t do it alone,” she said. “And H&R Block can’t do it alone. It’s going to take everybody getting involved.”

Sheldon Weisgrau, a spokesman for the Health Reform Resource Project, also praised the company.

“I assume they’re hoping this will lead to more people coming to them to have their taxes done,” he said. “But that’s fine. Anytime you’ve got someone providing accurate information it’s a positive.

Weisgrau said federal officials have announced plans for launching a major outreach campaign in June.

“They don’t want to start too early, which makes sense,” he said. “The exchange won’t be up and running until October.”

Mary McBain, chief executive of the Kansas Society of Certified Public Accountants CEO said the H&R Block initiative had not gone unnoticed.

“The major accounting firms have definitely been ramping up for this,” she said. “Some of the bigger firms have hired people just to work on ACA – that’s all they do.”

MacBain said her organization was committed to providing its members with accurate information about the law.

“All of us, I think, need to take a deep breath and not get caught up in all the emotion that’s comes with health care reform,” she said. “We need to be informed because, frankly, there’s a lot of misinformation out there.”

→ Find more information on health insurance exchanges and other health reform topics at khi.org/healthreform.

Federal health officials say hospital readmissions were down in 2012 for the first time in five years. Kansas readmission rates also are dropping and various projects are underway to further reduce them. by KHI News Service

Is the whirl of hospital revolving doors slowing?

Federal health officials are now reporting that the rate of preventable and costly hospital readmissions is down for the first time in more than five years, which meant about 70,000 fewer hospital returns nationally in 2012 for the Medicare program alone.

With a strong push from the federal health reform law, scores of medical and social service workers around Kansas — like thousands of their counterparts in other states — are working together on projects that officials say show promise for reducing avoidable readmissions.

If they succeed, hospitals could be spared some of the Affordable Care Act penalties they face in the form of reduced Medicare payments and federal health care spending could be trimmed $8.2 billion by 2019, if projections from the Office of the Actuary at the Centers for Medicare and Medicaid Services (CMS) prove accurate.

Starting in October 2012, almost 30 of the 46 non-exempt Kansas hospitals were punished for relatively high readmission rates in the first year of the ACA program, according to information from CMS compiled by Kaiser Health News, a partner of KHI News Service.

Financial sting

Because of the potential financial sting attached, nobody wants to be on that penalty list when it’s redrawn for this year, especially since last year’s maximum penalty of a 1 percent reduction will grow to a maximum 2 percent and then 3 percent for 2014.

“Almost every hospital is looking at this, because they stand to gain or lose,” said Ken Mishler, chief executive of the Kansas Foundation for Medical Care, a Topeka-based, non-profit organization that is the federal government’s sole designated contractor in Kansas for improving health care quality. In federal parlance, the foundation is known as a Quality Improvement Organization or QIO.

Mishler’s group was directly involved with organizing projects in four locations - Hays, Topeka, Kansas City and Wichita – but there are others underway, too, including one by the Kansas Healthcare Collaborative, a 2008 creation of the Kansas Hospital Association and the Kansas Medical Society.

Lower rates

There is evidence the various efforts, some of which predate the ACA, may be working. The readmission rate in Kansas was already lower than the national average, but recent numbers show even that somewhat lower rate has dropped.

According to the Kansas Foundation for Medical Care there were 49.4 per 1,000 Medicare fee-for-service patients readmitted to Kansas hospitals within 30 days in 2011 versus 52.5 in 2010. That compares favorably to the national average of 56.8 per 1,000 in 2011 and 58.2 per 1,000 in 2010. Foundation officials say the ultimate goal is a 20 percent reduction.

The efforts to make that happen in Kansas vary place to place but among the things they have in common is the involvement of multiple types of medical and social service providers or agencies, not just hospitals.

The reason for that, experts say, is that one of the best ways to reduce readmissions is to make sure that patients get proper follow-up care or attention after they are discharged whether they leave the hospital to live alone at home - where they may receive limited assistance from a variety of outside sources - or a skilled nursing facility where they get more-or-less 24-hour attention.

‘A community problem’

“It’s not just a hospital problem. It’s a community problem and you have to get all the providers together. It’s not easy work. It’s hard work,” said Laura Sanchez, the project director for the Kansas Foundation for Medical Care.

→ Continue reading on khi.org.

Projected job creation due to Medicaid expansion, according to a report issued by the Kansas Hospital Association. by KHI News Service

A study released today by the Kansas Hospital Association says that expanding Medicaid eligibility to levels called for in the federal health reform law would pump more than $3 billion into the state’s economy and create 4,000 new jobs by 2020.

The study, done for the association by the Center for Health Policy Research at George Washington University and Regional Economic Models, Inc., also shows that expansion would save the state more than it would cost.

Tom Bell, the association’s chief executive, said the projected economic benefits were too significant to be ignored by Gov. Sam Brownback and legislative leaders as they consider whether or not to expand eligibility for the healthcare program that serves poor, elderly and disabled Kansans.

Brownback has been a vocal opponent of the Affordable Care Act but has not made a decision on Medicaid expansion, which was made optional for states as the result of last year’s U.S. Supreme Court decision upholding the law.

“I think from our perspective, it’s not unlike the state landing a huge federal contract,” Bell said.

The impact of the expansion on the Kansas economy could rival that of the National Bio and Agro-Defense Facility in Manhattan, Bell said.

“That’s the way we look at it, as an opportunity for our state,” he said.

Bigger impact in Kansas

Since Jan. 1 in Kansas, the Medicaid program has operated under the name of KanCare. Three health insurance companies are under contract with the state administer it.

The health reform law requires that the federal government cover state costs of expanding Medicaid for three years. After that, the federal share would recede gradually until it reaches 90 percent, where it would remain.

Currently, Kansas’ Medicaid eligibility criteria for adults are among the most restrictive in the nation. Only those with children are eligible and only then if they earn less than 32 percent of the Federal Poverty Level (FPF) — currently $5,900 a year for a family of four.

Because those numbers are so low, expanding Medicaid would have a bigger impact in Kansas than in many other states by making all Kansans who earn up to 133 percent of FPL — $30,660 for a family of four — eligible for the program.

Various estimates suggest that expansion could add between 226,000 and 240,000 Kansans to the 380,000 now enrolled in Medicaid.

Net benefit to the state

A Kansas Department of Health and Environment report released last week estimated Medicaid costs would climb by $513 million over 10 years regardless of whether the state expanded eligibility for the program. That’s because heightened attention surrounding the expansion issue is expected to prompt many people who already are eligible but not enrolled to sign up.

Covering only those who are made eligible by the expansion would cost another $600 million over 10 years, the KDHE report said. Even so, the hospital association report said that expanding Medicaid would produce a net savings to the state of $82 million from 2014 to 2020.

“That’s front loaded into those first three years, but it’s still a substantial net benefit,” Bell said.

Governor undecided

Brownback has not ruled out expansion but neither has his administration shown much, if any, enthusiasm for the idea. Reacting to the KDHE cost estimate, Sherriene Jones-Sontag, the governor’s chief spokesperson, said expanding Medicaid would affect the state’s ability to fund other “core responsibilities.” The impact would be even greater “if the federal government fails to keep its promise to pay for its part of the expansion,” she said.

Bell said administrators at the association’s 126 member hospitals understand Brownback’s concerns, which are shared by many legislators. But he said they believe the Medicaid expansion dollars are needed to offset the anticipated loss of other federal funds that hospitals have used to cover the cost of caring for the uninsured.

“From an economic perspective for our members — especially those that treat a higher number of uninsured — they think it makes great sense to take a serious look this and see if we can make it work,” Bell said.

→ Find the various cost estimates of Medicaid expansion in Kansas, as well as archived coverage of the issue, here.

In the current fiscal year, Via Christi Health — which includes this hospital on St. Francis in Wichita — is expected to receive almost $13 million from the disproportionate share payments, the most of any health care provider in the state. Hospitals use the money, a mix of federal and state dollars, to offset some of the costs of caring for the uninsured. Under the Affordable Care Act, also known as Obamacare, those payments are to be significantly reduced in anticipation of more people being covered by Medicaid. However, the U.S. Supreme Court ruling gave states the option to not expand Medicaid — meaning if Kansas chooses not to expand its Medicaid program, the state's hospitals face the loss of significant funding and may have to cut staff or services, officials said. by KHI News Service

Many Kansas hospital officials say they are worried that if state policymakers choose not to expand eligibility for the state’s Medicaid program, the hospitals will see a significant drop in the money they receive to help care for patients who can’t or won’t pay their medical bills.

Currently, 64 of the state’s 127 hospitals divide about $51.3 million a year in what are called Medicaid disproportionate share payments.

They use the money, a mix of federal and state dollars, to offset some of the costs of caring for the uninsured.

“It’s a significant amount of funding for us,” said Bruce Witt, director of governmental relations at Via Christi Health in Wichita.

In the current fiscal year, Via Christi Health is expected to receive almost $13 million from the disproportionate share payments, the most of any health care provider in the state.

Under the Affordable Care Act, also known as Obamacare, those payments are to be significantly reduced, starting in October.

“We’re being told that ‘disproportionate share’ won’t be completely phased out, but that roughly 50 percent will be going away,” said Tom Bell, chief executive of the Kansas Hospital Association. “It may end up being somewhere between 50 and 75 percent. We don’t know at this point.”

Though Via Christi could expect to lose the most dollars, the smaller, rural hospitals likely would be the hardest hit proportionately based on an analysis done for the KHI News Service by its parent organization, the Kansas Health Institute. The analysis calculated the likely revenue hit on each Kansas hospital based on recent payment histories, bed counts and inpatient stays.

State option on Medicaid

The law’s design, Bell said, preceded the U.S. Supreme Court’s June 28, 2012 ruling that gives states the option of choosing to not expand their Medicaid coverage to include non-disabled, childless adults whose incomes fall below 133 percent of the federal poverty level.

Since the ruling, governors in at least 10 states – Alabama, Georgia, Idaho, Louisiana, Maine, Mississippi, South Carolina, South Dakota, Oklahoma, and Texas - have said they will not expand Medicaid eligibility.

“Our lieutenant governor is saying he’s not sure that DSH (disproportionate share) is going away because the (U.S.) Supreme Court has said the federal government can’t penalize states for not going along with the Medicaid expansion,” said Shawn Rossi, a vice president with the Mississippi Hospital Association.

“We don’t know if that’s a correct assumption,” Rossi said, “but we are for sure telling our legislators that if DSH goes away, we’re definitely going to need something to take its place. We see a very large number of people who are uninsured.”

Brownback looking it over

Kansas’ Gov. Sam Brownback has been an outspoken opponent of the Affordable Care Act, has not yet decided whether to implement the Medicaid expansion.

→ Continue reading on khi.org.

Mark Dugan, (right) chief of staff for Lt. Gov. Jeff Colyer, and KanCare ombudsman, James Bart. by KHI News Service

The Brownback administration has not ruled out implementing the Medicaid expansion called for in the federal health reform law.

But a spokesman today told members of the Legislature’s Joint Committee on Health Policy Oversight that prior to making a decision administration officials want to develop their own estimate of how many Kansans are likely to sign up for the health care program and how much the expansion would cost the state.

“We’re continuing to study the issue,” said Mark Dugan, chief of staff for Lt. Gov. Jeff Colyer. “We would like to come to you with our own numbers.”

Currently, there are several competing estimates of how the expansion would affect Medicaid enrollment and the cost of the program. The latest, released earlier this month by the Kansas Health Institute indicated that approximately 240,000 additional low-income, disabled and elderly Kansans would enroll in a program that currently serves about 380,000. According to the KHI analysis, expanding Medicaid would cost the state an additional $519 million between its implementation in 2014 and 2020.

The KHI projections are higher than those in a 2010 report prepared for the now defunct Kansas Health Policy Authority and also higher than those in a state-by-state analysis done in 2010 by the Kaiser Family Foundation. However, they considerably less than those estimated in 2011 by the Kansas Policy Institute, a conservative think-tank based in Wichita, which has opposed the Affordable Care Act.

The KHI News Service is an editorially independent program of KHI.

Currently, Kansas’ Medicaid eligibility criteria for adults are among the most restrictive in the nation. Only those with children are eligible and only then if they earn less than 32 percent of the Federal Poverty Level — $5,900 a year for a family of four.

The ACA expansion would have a bigger impact in Kansas than many states. It would raise the eligibility threshold for all Kansans to 133 percent of FPL — $30,660 for a family of four.

Two of the four legislators who braved inclement weather to attend Thursday’s meeting of the 12-member committee made it clear that they favored the expansion.

Rep. Don Hill, a moderate Republican from Emporia, said that virtually all legislators regardless of party and ideology agree that the current health care system is broken and in need of reform to lower costs and reduce the number of people who are either uninsured and under-insured.

He said while the ACA is far from perfect, “it has some redeeming elements.” One of those, he said, is the Medicaid expansion because of its potential to extend coverage to many of the state’s 365,000 uninsured.

Citing the federal government’s promise to shoulder the cost of serving all those made eligible by the expansion for the first three years, Sen. David Haley, a Kansas City Democrat, asked, “Why can’t we cover more Kansans and why shouldn’t we?”

“I think we’re going to take a good look at it,” Dugan answered.

But, Dugan said, a factor that must be considered is whether or not the cash-strapped federal government can be counted on to keep its funding promise. After paying all of the costs of the expansion for three years, the federal government would gradually reduce its commitment until it reached 90 percent, where it would be maintained.

“He (Gov. Brownback) doesn’t have a high degree of confidence in the federal government maintaining that 90 percent commitment over the long term,” Dugan said.

Dugan said the federal government missed an opportunity to negotiate a compromise with Republican governors skeptical of the expansion when it rejected the idea of allowing states to increase eligibility to only 100 percent of FPL.

“That was an opportunity for middle ground that was lost,” he said.

→ Download the various cost estimates of expanding Medicaid in Kansas at khi.org.

Robert Laszewski — a nationally renowned expert on health reform and president of Health Policy and Strategy Associates in Washington, D.C. by KHI News Service

→ Watch video below

Like Kansas Gov. Sam Brownback, Bob Laszewski is a staunch opponent of the Affordable Care Act.

Despite that, the Washington, D.C. consultant said at a meeting here today that Brownback is making a mistake by refusing to partner with the federal government to run the Kansas health insurance purchasing exchange that the law requires to be operational by 2014.

“Do the partnership. That is a no-brainer,” Laszewski said to about 100 legislators, lobbyists and health care providers at a meeting sponsored by the Kansas Health Institute, the parent organization of the KHI News Service.

Laszewski, whose client list consists mostly of health insurance companies, said it’s time for opponents of the law to stop fighting it and start doing what they can to ensure that it is implemented in a way that does the least harm to the industry and consumers. One way to do that, he said, would be to implement exchanges – new online marketplaces – that encourage competition among insurance companies rather than rely on regulations to moderate increases in premiums.

“Putting the insurance exchange up doesn’t mean you support the thing (the reform law), it means you are trying to minimize the damage,” Laszewski said, predicting that premiums in the individual and small-group markets would go up no matter who runs the exchanges.

Brownback last year blocked Kansas Insurance Commissioner Sandy Praeger’s attempts to establish a state-operated exchange, returning a $31.5 million federal grant in the process. Last month, the governor told Praeger, who also is a Republican, that he would not support her efforts to partner with the federal government to operate and fund the Kansas exchange.

“Kansans feel Obamacare is an overreach by Washington and have rejected the state’s participation in this federal program," Brownback said, explaining his decision.

Try again

Praeger, who also spoke at the KHI meeting, said she would try once more before a Feb. 15 federal deadline to convince the governor and legislators that partnering on an exchange would be better than allowing the federal government to run it. Federal officials recently extended the deadline in an effort to accommodate states where governors had opposed or held out on state participation pending the outcome of the November national elections.

“There is still some opportunity for us to retain some control,” Praeger said. “Our department looks forward to working with the Legislature and the governor to see if that still is an option. The decision really rests with them.”

Praeger said partnering with the federal government would allow her department to retain authority to approve the plans marketed in the exchange and manage consumer protection efforts. She said it might also prevent federal officials from over-regulating the exchange.

The ACA calls on states to expand Medicaid eligibility to include adults earning up to 138 percent of the federal poverty level — $30,660 a year for a family of four. But the U.S. Supreme Court decision earlier this year that upheld the law also made the program expansion optional for states.

Implementing the expansion in Kansas would make more than 300,000 additional adults eligible for a program that today serves approximately 380,000 Kansans – mainly women, children, seniors in nursing homes and people with disabilities.

A KHI analysis handed out at the meeting estimated that about 240,000 additional Kansans would enroll in Medicaid if the expansion were implemented in 2014, including 122,185 adults and 117,886 children. According to the analysis, expanding Medicaid would cost the state an additional $519 million between 2014 and 2020.

The projected cost and enrollment figures in the KHI analysis are higher than those in a 2010 report prepared for the now-defunct Kansas Health Policy Authority and also higher than those in a state-by-state analysis prepared in 2010 by the Kaiser Family Foundation. But the costs projected in the KHI analysis were considerably less than those estimated in 2011 by the Kansas Policy Institute, a conservative think-tank based in Wichita, which has opposed the Affordable Care Act and its implementation. The Kansas Policy Institute also projected the program’s cost through 2023.

Currently, the state’s Medicaid eligibility criteria for adults are among the most restrictive in the nation. Only those with children are eligible and then only if they earn less than 32 percent of FPL – $5,900 a year for a family of four.

Brownback hasn’t said whether he plans to implement or recommend the expansion for Kansas. But he has said that he doubts the federal government would keep its promise to initially pay 100 percent of the cost of serving all those newly made eligible by the Medicaid expansion. Under current law, the federal commitment would be good for the first three years, drop to 95 percent in 2017 and then to 90 percent in 2020, where it would remain.

Medicaid leverage

Laszewski said covering currently uninsured Kansans in Medicaid would be significantly cheaper for taxpayers than providing them with tax credits to purchase private coverage in the exchange. And he said by agreeing to the expansion, Brownback and other Republican governors might be able to get federal officials to agree to their long-standing request to convert the program to block grants to states with fewer restrictions on how the money is spent.

“Put up or shut up, that’s what I say to Republican governors,” Laszewski said. “It gives you leverage to get what you’ve always said you wanted — autonomy. Go to the Obama administration and say, ‘OK, we’ll expand Medicaid but we’re not going to do it your way.’”

→ Continue reading on khi.org.

Former State Rep. Carolyn Weinhold was among those who gathered at the Statehouse on Friday in support of expanding the state's Medicaid program. In the 1990s, Weinhold was a Democrat representing a Salina district. She now works for the Kansas Disability Rights Center in Topeka. by KHI News Service

About 100 people rallied outside the Kansas Statehouse Nov. 9, urging state officials to expand Medicaid eligiblity as provided for in the federal health reform law.

A Lawrence pastor cast the expansion as a Christian imperative during a call-and-response exercise with the crowd.

“If Jesus was up in the Capitol would he make a choice to keep 130,000 people without care?” said the Rev. Joshua Longbottom, associate pastor at Plymouth Congregational Church in Lawrence.

"No," the crowd shouted.

“If Jesus was up in the Capitol, would he tell families that they just need to get better jobs so that they could afford to take care of themselves?” Longbottom asked.

Again, the answer was "no."

“Did Jesus say, ‘I’m sorry you can’t get to the well, Mr. Leper, but you need to cultivate some self-reliance’?” Longbottom said.

“No,” the crowd yelled.

“So I ask the question, Gov. Brownback, ‘What would Jesus do?” Longbottom said. “I thought the mark of his ministry was caring for the ill, caring for the sick, caring for the dispossessed, caring for the marginalized, caring the first for the least.”

Longbottom said he hoped the governor wasn’t a “…politician who puts on his Christianity like it’s a cardigan (sweater), using it to gain access to a constituency.”

Brownback, a conservative Republican, has been outspoken about his Christianity and penned a spiritual autobiography titled "From Power to Purpose."

He's been a consistent political foe of the Affordable Care Act, also known as ObamaCare, first in the U.S. Senate and later as governor.

He has said repeatedly that the majority of Kansans are opposed to the reform law and cites the success of the law's opponents in recent state elections as the proof.

Expansion not ruled out

Last week, the governor announced that he would block the state’s participation in a state-federal insurance exchange, one of the hallmarks of the new law. But unlike some Republican governors, he hasn't ruled out the possibility he would support some sort of Medicaid expansion.

"The Medicaid expansion is a separate issue" from the insurance exchange, said chief Brownback spokesperson Sherriene Jones-Sontag in an email Friday to KHI News Service in response to a question asking if the governor would oppose opening up the program.

"We are continuing to discuss options and alternatives with like-minded states and with our legislative partners in Kansas," she said.

The U.S. Supreme Court has upheld the Affordable Care Act, but said the law couldn't oblige states to expand their Medicaid programs. The law gives states the option of expanding their Medicaid programs to include adults earning up to 133 percent of federal poverty guidelines.

→ Continue reading on khi.org.

Kansas Insurance Commissioner Sandy Praeger. by KHI News Service

Kansas Insurance Commissioner Sandy Praeger said today that she wants to meet this week with Gov. Sam Brownback about how to move forward with implementation of the federal health reform law.

Specifically, Praeger said she wants to talk to Brownback about the state partnering with the federal government on a health insurance purchasing exchange. Kansas no longer has the option of designing its own online insurance marketplace but it can still partner on one with federal officials, if it acts quickly, she said.

Praeger said partnering with the federal government on an exchange would allow the state to maintain its authority to review and license insurance plans.

Praeger, a moderate Republican who supports the reform law, said she must let federal officials know by Friday, Nov. 16 whether the state intends to partner on an exchange. But she said she needs the governor’s blessing on that and a grant application her department has prepared, which must be submitted by Thursday, Nov. 15.

“The governor needs to agree that he won’t oppose us applying for the grant,” Praeger said. “He doesn’t have to give tacit approval necessarily, but just indicate it’s OK if we want to move forward on this.”

Brownback, a conservative Republican, voted against the Affordable Care Act as a member of the U.S. Senate and as governor has tried to block its implementation pending the outcome of a U.S. Supreme Court ruling on the law and then later the outcome of the presidential race.

Brownback in August 2011 rejected a $31.5 million federal grant intended to help Kansas develop an exchange as part of a program to develop models for other states to use.

Praeger said President Obama’s re-election means that the reform law won’t be repealed. It also means that states that have been slow to act will have to play catch up to meet approaching implementation deadlines.

Under the law, each state is to have an exchange operational by Jan. 2014.

“It’s time to stop resisting,” Praeger said.

→ Continue reading on khi.org.

Lt. Gov. Jeff Colyer — a point man for Gov. Sam Brownback's plan to remake the state's Medicaid program — speaking about the proposed KanCare reforms at a public event in Overland Park on Thursday. by KHI News Service

A Kansas health consumer group is planning a post-election rally at the Statehouse in support of expanding the state’s Medicaid program.

Meanwhile, Lt. Gov. Jeff Colyer today headlined an event in Overland Park that was sponsored by a conservative think tank that opposes broadening the Medicaid program. Colyer, however, didn't make explicit what intentions, if any, the administration of Gov. Sam Brownback might have with respect to the issue.

Anna Lambertson, executive director of the Kansas Health Consumer Coalition, said the group "wants to get the dialogue started," on the potential benefits for Kansans, if policymakers here decide they will open up eligibility to include adults earning up to 133 percent of federal poverty guidelines.

Currently, the state's Medicaid program is mostly restricted to poor children, pregnant women, the disabled and the elderly. A non-disabled adult rearing children is currently eligible for Medicaid, if his or her income is below 32 percent of the poverty level – about $5,200 a year for a young mother with two children.

Kansas’ eligibility threshold is among the lowest in the nation.

Affordable Care Act

Under the federal Affordable Care Act, commonly referred to as Obamacare, states would have the option of expanding their Medicaid programs to include adults with incomes at or below 133 percent of federal poverty guidelines or about $30,700 a year for a parent in a four-person household or about $14,900 a year for a childless adult.

Brownback, an outspoken critic of the health reform law, has said he won't consider any aspect of the health reform law's implementation, including a possible Medicaid expansion, until after the Nov. 6 election.

Republican presidential candidate Mitt Romney has pledged to repeal the law, if elected.

Governors in at least six states – Florida, Georgia, Louisiana, Mississippi, South Carolina, and Texas – have said they will reject the expansion, citing concerns that it would prove to be too expensive and would expand – rather than shrink – the role of government.

Governors in at least 13 states have said they will expand the program.

According to a preliminary estimate by analysts at the Kansas Health Institute, if the expansion is approved here it could add 130,000 people to Kansas Medicaid by 2019.

Colyer was the main speaker at a Kansas Policy Institute (KPI) meeting today in Overland Park that drew about 60 people. He confined his remarks to describing the administration's rationale and goals for its KanCare Medicaid reforms.

He didn't offer new information, but instead repeated points he and other administration officials have made in various venues since unveiling their plan about a year ago. He didn't touch on the question of Medicaid expansion and did not take queries from the audience before leaving for another engagement.

'Crowd out'

But earlier in the two-hour event, KPI President Dave Trabert said that expanding Medicaid in the state could increase the program's enrollment by 254,000 people by 2023 and increase state general fund spending on Medicaid by $4.7 billion within a decade.

Under the law, the federal government, starting Jan. 1, 2014, would finance 100 percent of the costs of covering the newly eligible Medicaid enrollees for three years: 2014, 2015, and 2016.

The federal match would drop to 95 percent in 2017; 94 percent in 2018; 93 percent in 2019; and 90 percent in 2020 and beyond.

Currently, the federal government picks up about 57 percent of the state’s Medicaid cost. The state pays the remainder.

→ Continue reading on khi.org.

Jay Angoff, director of the U.S. Health and Human Services Department region that includes Missouri, Kansas, Nebraska and Iowa; and HHS Secretary Kathleen Sebelius. by KHI News Service

Talk of repealing the Affordable Care Act is partisan bluster that won’t come to pass even if Republicans sweep the November elections, a top Obama administration health care official predicted at a forum here today.

“Even those people who are talking about repealing, privately, they acknowledge that no, the law is here to stay,” said Jay Angoff, director of the U.S. Health and Human Services Department region that includes Missouri, Kansas, Nebraska and Iowa.

Angoff said that even if Republicans control the White House and U.S. House following the election, they would not have a large enough majority in the Senate to push through legislation to overturn the law. Senate rules require 60 votes to advance most legislation.

Angoff is a former Missouri insurance commissioner and has served as an advisor to Health and Human Services Secretary Kathleen Sebelius on health insurance cost and coverage issues. The forum, organized by the Health Care Foundation of Greater Kansas City, drew an audience of about 50 people.

'When the dust settles'

Kansas State Rep. Jim Denning, an Overland Park Republican, disputed Angoff’s comments, including taking issue with the director’s analysis of the potential congressional repeal. Denning is the retired chief executive of Discover Vision Centers, which has eight locations in Missouri and Kansas.

Angoff also predicted that states eventually would go along with the expansion of Medicaid eligibility included in the Affordable Care Act.

“When the dust settles,” he said, “states are going to realize what a terrific deal this is.”

In its June 28 ruling on the reform law, the U.S. Supreme Court left it up to the states to decide if they want to participate in the expanded Medicaid program.

Under the law, the federal government would pay 100 percent of the costs of the newly eligible Medicaid enrollees when the provision takes effect in 2014, gradually reducing its share to 90 percent by 2020.

The expanded eligibility would take in low-income residents under the age of 65 who earn up to 138 percent of the federal poverty level.

Kansas currently covers more than 350,000 individuals under its Medicaid program. Preliminary estimates project the state’s enrollment could increase by about 130,000 individuals under the health law expansion.

The Kansas Medicaid program costs about $2.8 billion a year. The federal government currently covers about 60 percent of the cost.

Good for small business

Angoff also said the Affordable Care Act was a great deal for small businesses, despite the fact that the National Federation of Independent Businesses was a lead challenger of the law in the suit before the Supreme Court.

He noted a provision that provides tax credits to businesses with 25 or fewer workers that offer health insurance to their workers.

Roughly 360,000 small businesses have already received assistance under that program, Angoff said, and more than 1 million more are eligible.

“We think it’s a great victory for the American public,” Angoff said of the Supreme Court decision.

Denning said it wouldn’t take a 60-vote majority in the Senate to repeal the Affordable Care Act.

'No money'

He said the Senate could overturn the act with a simple majority through the budget process, much the way the law was passed in the first place.

He also disagreed that the Medicaid expansion was a good deal.

“This is not free money,” Denning said. “The federal government has no money.”

He said the federal government would have to run up its debt to pay for the Medicaid expansion.

He also said he was concerned that the federal government would pay for the expansion the first few years but then would pull back, leaving states to pick up more and more of the tab.

Denning also said the tax credit program for small businesses has not been nearly as popular as Angoff made it seem.

“He’s just talking sound bite stuff there,” Denning said of Angoff's remarks.

The tax credit program was complicated and resulted in costly plans that insurance brokers had little luck in pushing with their business customers, he said.

→ Full coverage of health reform, including a short video explaining what the law means for you at khi.org/healthreform

James Carlson, CEO of Amerigroup, one of the private insurance companies that recently signed Medicaid managed care contracts with the state of Kansas. by KHI News Service

The chief executive officer of one of the private insurance companies that recently signed Medicaid managed care contracts with the state of Kansas said today that states shouldn’t refuse the offer of additional federal money to expand their programs.

James Carlson, CEO of Amerigroup, made the comment during a discussion with Wall Street analysts about his company’s potential sale to insurance giant WellPoint.

“When you step back from this, there are billions of dollars of federal money that are going to flow into states,” Carlson said in a report published by Politico. “We think the states are going to need to take it.”

Kansas insurance officials are evaluating WellPoint’s bid for Amerigroup, which is one of three companies selected by the state to manage care provided to the approximately 350,000 poor, elderly and disabled Kansans enrolled in Medicaid. The other two are United Healthcare of the Midwest, a subsidiary of United Healthcare, and Sunflower State Health Plan, a subsidiary of Centene.

Several Republican governors have said they don’t intend to expand eligibility for their Medicaid programs now that the U.S. Supreme Court has ruled that the federal government can’t withhold its share of funding for the program in states that decline to do so.

Kansas Gov. Sam Brownback has reiterated his opposition to the Affordable Care Act in statements since the ruling, but he has stopped short of saying the state won’t implement the Medicaid expansion on schedule in 2014.

Brownback spokesperson Sherriene Jones-Sontag said the governor still favors repeal of the health reform law and has urged voters to reject it at the polls in November by voting against President Obama’s re-election.

The expansion would result in a more dramatic increase in Medicaid eligibility in Kansas compared to other states. Currently, Kansas adults with dependent children can’t qualify for the program unless they earn less than 27 percent of the federal poverty threshold – about $6,000 for a family of four. Adults without children aren’t eligible for Medicaid unless they are disabled.

The ACA expansion would make everyone who earns less than 133 percent of the poverty threshold eligible for Medicaid. That means a family of four could earn up to about $30,000 and still qualify.

If implemented, the expansion could add as many as 150,000 Kansans to Medicaid rolls.

Related coverage on KHI.org:

→ Poor Kansans and providers have a lot riding on Medicaid decision

→ Kansas AG claims partial victory in health reform case

→ States balk at expanding Medicaid

Politicians are still arguing over the Affordable Care Act and Gov. Sam Brownback says he wants no part of the federal reform. But Kansas hospitals and other medical providers have been quietly going about their business adopting or preparing for the law's major provisions. by KHI News Service

Republicans are working still to repeal it, but even before the U.S. Supreme Court ruled that the Affordable Care Act was constitutional, many of its major changes were under way for Kansas hospitals, doctors and other medical providers.

In fact, some representatives of doctor and hospital groups in Kansas and nationally say that many key requirements of the law were inevitable or bound to happen with or without the law, simply because the status quo of the health care industry was unsustainable because of its costs.

In 1965, U.S. health care spending accounted for about 6 percent of the gross domestic product; by 2009, it represented about 17 percent. One culprit for the rising cost, experts say, has been payment systems that reimburse providers more for the volume of their services than for the quality or effectiveness of the care.

“I don't want to downplay the significance of the (Supreme Court) ruling,” said Tom Bell, chief executive of the Kansas Hospital Association, “but I think it’s been clear for some time that a lot of the ways that the system is changing - the movement away from fee-for-service, value-based purchasing, those sorts of things - those things were going to continue whether this law was struck down or upheld. ... So from that perspective, (the decision) was maybe not quite as momentous as we’ve been hearing on the cable news networks.”

A report on the ACA by the national Physicians Foundation published soon after the law was passed in 2010 generally was negative about the reform’s anticipated consequences, particularly for the 32 percent of the nation’s doctors working in individual, private practices of one or two physicians. For them, the authors concluded, the law almost certainly means that their forms of practice “will be largely, though not uniformly, replaced” by new arrangements that will make many of them salaried employees of hospitals or larger group practices.

Nonetheless, the report concluded, “health reform was necessary and inevitable. The impetus of informal reform would likely have spurred many of the changes (required by the ACA) independent of formal reform.”

Quietly moving forward

So as politicians continue to fight over the law, forward-looking hospitals and doctors for at least the past two years quietly have been preparing for and adopting its various provisions.

“The Supreme Court’s ruling keeps in place improved access to health care through expanded insurance coverage and important insurance reforms, which were key elements of the Affordable Care Act,” said Jeff Korsmo, chief executive of Via Christi Health, a Catholic-affiliated system that is the largest private provider of health services in Kansas. “The way we deliver health care has been changing since the Affordable Care Act took effect two years ago, and it will need to change even more dramatically in the years ahead.

“The growth in the cost of health care in the United States is simply unsustainable,” Korsmo said after the court ruling, “and it’s going to get worse because 10,000 baby boomers a day are reaching Medicare age. Those costs, combined with our federal and state governments’ fiscal challenges, all call for major change in health care.”

→ Continue reading on khi.org.

The Kansas Health Institute convened a July 2 discussion of the Supreme Court's health reform ruling and its immediate implications for Kansas. Panelists were (from right) Tom Bell, Sandy Praeger, Jay Angoff, Bill Rich, Suzanne Schrandt and moderator Robert St. Peter. About 80 people attended in person and 82 attended via live webcast. by KHI News Service

The head of the Kansas Hospital Association said today that most of the group's member hospitals have accepted the U.S. Supreme Court decision to uphold the Affordable Care Act and are ready to embrace reform.

“The number one thing I’m hearing from my people is, ‘Oh my gosh, are we going to have to go through this health reform political debate again?’” said Tom Bell, noting that he and other health care officials had hoped the ruling would give them a clearer picture of the future.

So far, he said, that’s not happened.

“I’m not so sure that – because of our political environment – we have any more certainty today than we did last week,” he said. “It’s hard to plan.”

Bell spoke during a Kansas Health Institute-sponsored panel discussion on the court’s ruling. Also participating on the panel were:

• Bill Rich, professor of constitutional law at Washburn University School of Law.

• Kansas Insurance Commissioner Sandy Praeger.

• Jay Angoff, director of the U.S. Health and Human Services regional office in Kansas City.

Angoff told the audience that over time “cooler heads are going to prevail” as the public learns more about the law’s benefits and costs.

Medicaid expansion

The court's decision left intact the law's requirement that everyone who can afford health insurance buy it or pay a penalty. But the ruling also made the law's planned Medicaid expansion optional for states. Several Republican governors already have said they do not intend to expand Medicaid eligibility in their states. Gov. Sam Brownback hasn't said yet what his intentions might be with respect to the expansion, which could mean as many as 130,000 additional Kansans would gain eligibility.

Brownback has said he would take no steps to implement the Affordable Care Act until after the November elections, based on the assumption that Republicans will prevail in their bid for control of the White House and Congress and then repeal the law.

If Kansas opts not to expand its Medicaid coverage, Bell said, the state’s hospitals would be put in a position of still having to care for thousands of uninsured people in their emergency rooms while losing millions of dollars in federal disproportionate share payments.

Currently, the disproportionate share payments are meant to help hospitals offset the costs of caring for the uninsured.

Under the Affordable Care Act, Bell said, the payments would be phased out because it assumes the vast majority of the hospitals’ patients will be insured under Medicaid or otherwise by 2014, when the law's major coverage provisions are scheduled to kick in.

“There are a lot of things that really need to be looked at closely,” Bell said.

A Wichita legislator who attended the event said he thought fellow lawmakers would act in the 2013 legislative session to authorize Kansas' participation in the Medicaid expansion.

“If you’re a legislator and the hospitals’ (profit) margins in your district are tied to their DSH (disproportionate share) payments, how do you vote against giving them more patients with insurance through a Medicaid expansion if you know there isn’t going to be anything to replace the DSH payments with?” said Rep. Jim Ward, a Wichita Democrat who serves on the House Health and Services Committee. “At what point does ideology get by the practical reality?”

→ Continue reading and view full webcast of the panel discussion at khi.org.

→ Related story: States balk at expanding Medicaid

Kansas Insurance Commissioner Sandy Praeger. by KHI News Service

In the wake of today's U.S. Supreme Court ruling, Kansas could still avoid ceding total control of its health insurance exchange to the federal government if it moves quickly, Insurance Commissioner Sandy Praeger said.

“That’s probably the best-case scenario now from an exchange standpoint,” Praeger said.

But that would require a meeting of the minds between Praeger and Gov. Sam Brownback and meeting a mid-November deadline for alerting federal officials to the state's intentions.

Last year, Brownback returned a $31.5 million federal grant that would have helped the state develop its own exchange. And today, after the court's decision, the governor vowed he would do nothing to implement the Affordable Care Act's provisions until after the November elections.

“Stopping ObamaCare is now in the hands of the American people," Brownback said. "It begins with electing a new president this fall.”

Opposition from Brownback and Republican legislative leaders resulted in Kansas missing deadlines for establishing its own exchange. Under the federal law, each state must have an operational exchange by Jan. 1, 2014, with plans for it certified by Jan. 1, 2013. States that choose not to implement an exchange on their own would cede that authority to federal officials.

Kansas missed the cutoff for developing its own exchange but could still partner with the federal government on one, an arrangement that Praeger said would allow state officials to set rules for insurance company participation in the online marketplace and direct consumer assistance efforts.

“Plan management and consumer assistance are two functions that our industry and our agent community are most concerned about. So, I think they would like us to retain control,” Praeger said.

Praeger said federal officials have told her that she doesn’t need explicit authorization from Brownback to proceed. She could sign the letter declaring the state’s intention to partner with the federal government on an exchange.

Despite those assurances, Praeger, a moderate Republican who supports the health reform law, said she doesn’t want to circumvent Brownback, a conservative Republican who continues to fight the law.

“Even if I’m allowed to sign the letter, I’m not going to do that unless the governor at least agrees they won’t try to block our efforts,” Praeger said. “After the dust settles, I think we (Praeger and Brownback) will have a conversation and we’ll sort through all of the issues.”

As outlined in the Affordable Care Act, individuals, small-business owners and people whose incomes qualify them for federal subsidies and tax credits would shop for policies using the exchange websites that would help the shoppers sort through coverage and price options. The exchange also could be used to determine eligibility for the Medicaid program, eligibility for which would be expanded under the law where states choose to do so.

→ More in-depth coverage of the Supreme Court's ruling on health reform and its implications for Kansas at khi.org/aca-ruling.

by KHI News Service

To help Kansans better understand the health reform law, the problems it was intended to address and the issues that prompted Kansas and 25 other states to challenge it in court, the Kansas Health Institute recently talked to several experts. Excerpts from those conversations are featured in this collection of short videos. Each offers an informed perspective on the law and the controversy that surrounds it as the U.S. Supreme Court prepares to rule on its constitutionality this month.

Maynard Oliverius, CEO, Stormont-Vail HealthCare Topeka

Oliverius, a longtime hospital administrator, provides a historical viewpoint on health reform and its ultimate goal of improving access to health care for all Americans. “The Affordable Care Act is really a continuation of a public health policy that was formulated really back in the 1940s,” he says. As part of the health reform law passed in 2010, he says, hospitals agreed to forgo $155 billion in Medicare compensation with the expectation that 32 million Americans who now are uninsured will gain coverage through Medicaid or the insurance exchanges.

Oliverius acknowledges that the health reform law has flaws but says, “What I would hope is that Congress would look at the law, tweak, fix those things that need to be adjusted and fixed, and try to move away from the political ideology war that seems to be going on today.”

This is the first of six short videos. Click here to watch the next video, or jump to others in the series below...

→ Sandy Praeger, Kansas Insurance Commissioner

→ Derek Schmidt, Kansas Attorney General

→ Matt All, VP Blue Cross Blue Shield of Kansas

→ Suzanne Schrandt, Senior Analyst, Kansas Health Institute

→ Jay Angoff, Acting Regional Director, U.S. Department of Health and Human Services

by KHI News Service

Kansas Attorney General Derek Schmidt said he was encouraged by questions raised today by the U.S. Supreme Court justices as they heard legal arguments in defense of the federal health reform law.

"I feel better about our position now than I did before the arguments occurred," Schmidt said during a joint telephone press conference with U.S. Sens. Pat Roberts and Jerry Moran, both Kansas Republicans.

Schmidt, also a Republican, was among those present as the justices held a second day of oral arguments in the case.

Kansas is one of 26 states mounting the challenge to the Affordable Care Act.

Justices today wrestled for two hours with the most controversial element of the law — the so-called "individual mandate."

The mandate — scheduled to become effective Jan. 1, 2014 — would require virtually all Americans who can afford health insurance to have it or pay tax penalties. The states argue that the federal government cannot compel individuals into economic activity, such as buying insurance, and then claim power to regulate that activity under the Constitution's commerce clause.

Shared skepticism

"It was very clear that a majority of justices, at a minimum, share our skepticism about the federal government's authority to enact the mandate," Schmidt said. "All of the conservative justices — with the exception of Justice (Clarence) Thomas were active in their questioning, the questioning was pointed. For some of us it was very heartening that particularly Justice (Anthony) Kennedy seemed to pick up a number of points that we've been talking about."

Thomas rarely speaks during court proceedings. Kennedy is often a swing vote on the court, which is composed of five Republican appointees and four Democratic appointees. Many court watchers consider him a barometer of how the court might rule.

Schmidt said that he heard the states' arguments against the law reflected in Kennedy's questions.

"Doesn't this mandate change the relationship between the federal government and our citizens?" Schmidt said paraphrasing Kennedy. "The fact that that was where Justice Kennedy chose to focus in his initial round of questioning suggested from my vantage point that he is very much focused on the types of concerns we have."

Washburn University law professor Bill Rich said the justices' questions didn't necessarily mean they would end up voting to overturn the law. He said nothing he had heard in the first two days of arguments had changed his mind that a majority of justices would vote to uphold the law.

“If they’re consistent with the reasoning that they have previously provided for us in other opinions, then it’s most likely they will uphold this law,” said Rich, who teaches constitutional law. “There hasn’t been a major piece of legislation like this struck down by the Court in the last 75 years. And so it would be a pretty radical departure, a clear case of activist judges striking down an act of Congress, if that were to happen.”

If justices only strike down the individual mandate and let the rest of the law stand, then Congress should start over, Moran said.

"If it's determined to be unconstitutional, then the Affordable Care Act — to whatever degree it's going to work — the whole theory behind it falls apart. Congress would have to start over," he said.

The mandate

The lawyer for the federal government argued that without the individual mandate other provisions of the law are not viable — namely the requirement that insurance companies cover everyone, even those with pre-existing conditions. Without the mandate, people could wait until they are sick to buy coverage.

Beginning in the mid-1990s, the individual mandate was supported by some Republicans — including U.S. Senate Minority Leader Bob Dole — as an alternative to the health reform effort being lead by Hillary Clinton.

→ Continue reading this story, and find more coverage including full audio from the Supreme Court hearings at khi.org.

by KHI News Service

Kansas was among the last of 26 states to join the multistate lawsuit challenging the constitutionality of the Affordable Care Act.

Newly sworn in Kansas Attorney General Derek Schmidt asked to join the lawsuit on Jan. 12, 2011. A federal judge in Florida granted his request about a week later.

That case has now made it to the U.S. Supreme Court, which began an unprecedented three days of hearings on it this week.

Schmidt, a Republican, made a promise to join the lawsuit a cornerstone of his campaign to unseat Democrat Steve Six, who a few weeks before the 2010 election said he had considered the case but had decided against pursuing it.

“It seemed like there wasn’t too much of a constitutional argument to it,” Six told the Lawrence Journal-World at the time. In addition, Six said, he thought that “the cost of getting involved” outweighed any benefits the state would realize if the lawsuit was successful.

Six’s refusal to join the lawsuit triggered an onslaught of negative advertising during the final weeks of the campaign. An Iowa-based group called American Future Fund spent about $1 million on television ads that criticized Six for refusing to join the legal challenge to the ACA. No one yet knows who funded the ad campaign because state law doesn’t require political action committees to disclose their donors.

Not expensive after all

Some of the first states to join Florida in the case contributed $20,000 each to the cause. States that later joined the case paid $10,000 or $5,000. But Schmidt said because the plaintiffs wanted to reach a critical mass of states, Kansas was allowed to join the lawsuit at no cost.

“There was obviously some attraction, from the standpoint of those states, to having more than half the states joined in this battle,” Schmidt said in an interview with the KHI News Service (read the full interview here). “At the same time, I had an interest in not having Kansas spend money on the challenge. And so we were able to work out an accommodation where we joined but weren’t asked to join financially.”

Even so, Schmidt said, “we’re full partners in the litigation.”

Schmidt is in Washington, D.C., this week sitting in on the arguments. He said he wanted to attend because the case is “a big piece of history and Kansas is part of it.”

Strong case?

Schmidt said he believed the states challenging the health reform law had strong arguments on the two main issues in the case: That Congress exceeded its constitutional authority by mandating that virtually all Americans purchase health insurance and by requiring states to significantly expand eligibility for their Medicaid programs.

The federal government has the power to regulate interstate commerce. But, Schmidt said, it doesn’t have the authority to compel commerce so that it can regulate it.

“Part of our argument, and we think it’s a very strong legal argument, is that it is such an attractive power. The fact that Congress hasn’t used it in more than two centuries suggests that nobody thought it existed until a creative Congress came up with it two years ago,” he said.

→ Continue reading at khi.org/aca-scotus.

Related stories

→ Interview: Attorney Derek Schmidt on the legal challenge of the health reform law

→ The Health Law and The Supreme Court: A primer for the upcoming oral arguments