Posts tagged with Expansion
Not much was known about the benefits of Medicaid relative to its cost until a kind of enrollment lottery in Oregon created an unusual opportunity for researchers.
In 2008, Oregon officials decided to pare down a Medicaid waiting list but they only had enough money to cover a fraction of the approximately 85,000 people wanting coverage. They decided a lottery was the fairest way to determine who got in and who didn’t.
The unique selection process resulted in two groups of people who shared similar characteristics but unequal access to the health care system. It didn’t take researchers long to realize they had a ready-made study group and a control group.
“It let us study the effects of insurance using a real, randomized control group,” said Kate Baicker, a professor of health economics at the Harvard School of Public Health. “That’s important because people who are on Medicaid look really different from the uninsured population.”
Baicker and her colleagues went to work.
They studied thousands of people — some who were selected in the Medicaid lottery and some who were not — to measure the extent to which Medicaid improved the lives and the health of those who received coverage.
The resulting studies have generated a wealth of information for policymakers about both the benefits of Medicaid and the factors that contribute to its escalating cost.
The study results are now front and center in the Medicaid expansion debate as governors and legislators across the country attempt to decide whether the benefits of covering millions more Americans outweigh the increased costs to taxpayers.
Baicker is scheduled to be in Topeka to speak about Medicaid expansion on Tuesday at a luncheon being organized by the Kansas Health Institute, the parent organization of the KHI News Service. A number of legislators and other health policymakers are expected at the event.
Kansas is one of 23 states that have chosen not to expand their Medicaid programs to include adults whose incomes are below 138 percent of the federal poverty line.
The decision means that approximately 85,000 uninsured Kansans may fall into in what is being called the “Medicaid gap.” They are ineligible for Medicaid but still too poor to qualify for federal subsidies that would all but cover the cost of private coverage purchased in the new marketplace created by the Affordable Care Act.
'Yes' to both questions
So, is Medicaid expansion a good thing that will benefit millions of people or a costly expansion of the safety net that could strain federal and state budgets? It’s both, Baicker said.
“I think we can eliminate both the unduly optimistic view of the program and the unduly pessimistic view of the program,” she said.
→ Continue reading at KHI.org/baicker
→ Tune in for free webstream of Baicker's presentation 12:30 p.m. Jan. 28 at KHI.org/baickerstream
House Speaker Ray Merrick said it will be up to Gov. Sam Brownback to initiate discussions this year in the Legislature about possible Medicaid expansion.
"That’s the governor’s decision and I’ll wait for him to decide what he’s going to do with it," Merrick said in a pre-session press conference this afternoon. "He can request it and we can take it up."
Legislators last year passed a proviso stating that the program could not be expanded without "express approval" of the Legislature, so Merrick's comments indicate the GOP-dominated House is unlikely to give the issue much consideration without a push from the Governor's Office.
Merrick, a Stilwell Republican, said he didn't know yet how much interest fellow House members might have for reconsidering a broadening of the program, which currently is funded about 60 percent by the federal government and provides health coverage to about 380,000 poor Kansans, most of whom are disabled or elderly.
"This is a new year," Merrick said. "I really don't know" how many of the 125 House members might want to wade into the issue.
Between 58,000 and 85,000 Kansans could gain coverage, according to various estimates, if eligibility restrictions were relaxed in accordance with the federal Affordable Care Act, more commonly referred to as Obamacare. The federal law also calls for the feds to pay 100 percent of the cost of covering those newly eligible for Medicaid as a result of expansion. The federal match would drop to 90 percent after 2016.
Senate President Susan Wagle, a Wichita Republican, said earlier this week that she thought any sort of expansion would be difficult to get passed this year in light of the problems that accompanied the launch of the HealthCare.gov online insurance marketplace. But she said she thought the issue was worth debate and consideration.
She said she was interested in studying something like a plan proposed by Pennsylvania Gov. Tom Corbett, which would require program enrollees to be seeking work and also limit the number of doctor visits. The Pennsylvania plan, like some others being implemented or considered in Republican-dominated states, would use federal Medicaid dollars to buy enrollees coverage from private health plans.
In the past Brownback has said expansion would be up to the Legislature. But administration officials also recently have said that they continue to study the issue and what other states are doing about it.
Sara Belfry, a spokesperson for the governor, said this today when asked for comment on Medicaid expansion:
"Obamacare is fundamentally flawed and the disastrous rollout is just another indicator of the problems we will continue to see," she said. "Gov. Brownback's first priority is to extend KanCare (the state's name for Medicaid) to those who need it most: Kansans with disabilities on waiting lists for services."
The Kansas Hospital Association and a coalition of more than 50 social service and consumer advocacy groups are pushing policymakers to open up the Medicaid program to more people. Under the Affordable Care Act, hospitals stand to lose money they currently receive for treating the uninsured and without state approval of Medicaid expansion will not be able to offset those losses with additional Medicaid income.
Kathleen Christian is a remarkably healthy 63-year-old. She has no chronic conditions and rarely sees the doctor for anything other than preventive care.
Even so, she said she had been looking forward to getting health insurance under the Affordable Care Act, after having been without coverage since she was laid off in 2009.
But last month, Christian learned she would not be able to get coverage after all.
Because Kansas has not expanded Medicaid eligibility under the ACA, she is one of an estimated 85,000 Kansans who experts predict will fall into the so-called "Medicaid coverage gap."
Christian is not eligible for Medicaid (also known as KanCare in Kansas) because she earns too much to qualify for it but she is too poor to qualify for the ACA’s federal tax credits to buy private insurance.
Without the subsidies, there is simply no way she could afford $384 each month for the cheapest plan on HealthCare.gov, Christian said.
"Where am I supposed to get $384 every month? I budget and keep a spreadsheet. I know where every penny goes," Christian said.
Her 2012 adjusted gross income from part-time work was $5,008 and her monthly Social Security checks are about $800, she said.
"The last day of (November), I had $2.96 to my name. By the grace of God, every time I run out, usually the next day I have something to work with," she said. "I'm not alone. I know lots of people like me, lots of people who are struggling. There's just no way they can pay these premiums. It's just not realistic."
Christian said she lays equal blame on President Obama and Gov. Sam Brownback, who has opposed provisions of the ACA from the beginning.
"They're just a bunch of boys having an argument about who's better than who. It's all a political game for them. I don't think they're really seeing what they're doing to people," Christian said. "I guess people who have money just don't understand what being poor is. I'm not materialistically poor — I have a roof over my head, thank God, and we have enough food, although we could use a little bit more. We're not starving to death. But we're cash poor. That's just the way it is."
Christian said when she found out she'd be in the coverage gap, she wrote a letter to Brownback expressing her frustration:
She was laid off from her long-time job at a Lawrence home security company during the recession, she said.
Apart from a minimum wage job capped at 18 hours a week and the occasional temp job, she’s been out of work since.
"I'm in my sixties. It's not real easy to get a job," Christian said.
She has custody of her 13-year-old grandson and gets $115 per month in food stamps.
"It was $135, until they cut it back," she said.
When push came to shove, she filed for early retirement to get the Social Security payments, a move that means she gets lower monthly payments than if she had waited longer to take retirement.
"It was the only way I could support us. I didn't want to do early retirement, but I had no choice," she said.
Her grandson is covered by KanCare, which has less restrictive income requirements for children and pregnant women, but she has no health insurance. She pays for her dental cleanings every six months out of pocket.
"At this point, I'm just biding my time until I can get Medicare," she said.
Christian said she wrote to Brownback hoping a personal story might "get through to him."
“I told him that, as far as I'm concerned, the state of Kansas should be paying the premium credits for those people who do not qualify. I told him that maybe $384 is chump change to him and his people, but it's a lot of money for me,” she said.
Brownback spokesperson Sara Belfry acknowledged receipt of Christian’s letter.
“We did receive a letter from Kathleen (and), like all other correspondence we receive from constituents, we sent a response,” Belfry wrote in an email. “Beyond that, I have no further comment.”
Christian said that, as of this evening, she had yet to receive a response.
State lawmakers' resistance to expanding Medicaid “just makes no sense,” Kansas Insurance Commissioner Sandy Praeger said Thursday, speaking at a meeting of safety-net clinic officials.
Many legislators, she said, “really don't understand” the consequences of not expanding Medicaid because there was “almost no discussion of the Affordable Care Act” during this year's legislative session.
Praeger, who has been hosting a series of informational forums on the health reform law for the past three weeks, said legislators will have a hard time not addressing Medicaid expansion in 2014.
“People are starting to understand what the lack of Medicaid expansion means,” she said. “And I think legislators are starting to hear from them.”
Currently in Kansas, non-disabled adults with children are eligible for Medicaid if their incomes fall below 32 percent of the federal poverty level, roughly $6,250 a year for a family of three.
“Let me put that in perspective for you,” said Health Reform Resource Project Director Sheldon Weisgrau, who also spoke at the annual conference of the Kansas Association for the Medically Underserved. “That means that a mother with two kids who works a minimum-wage job half-time makes too much money to be on Medicaid,” though the children would qualify.
Childless, non-disabled adults, are not eligible for Medicaid “under any circumstances,” he said.
Under the Affordable Care Act, commonly known as Obamacare, the federal government will cover all or most of the costs of expanding Medicaid to include adults whose incomes fall below 138 percent of the poverty level. However, expansion is optional and up to the political leaders in each state.
Low-income children and pregnant women already are covered under Medicaid.
In Kansas, Medicaid expansion would insure about 130,000 adults who are currently uninsured, according to various estimates.
Gov. Sam Brownback and the Republican majorities in both the House and Senate have shelved the Medicaid-expansion debate, saying they doubt the federal government will be able to keep its promise to cover most of the costs.
Cost of expansion
If adopted, Medicaid expansion would cost the state about $625 million over 10 years, according to a projection by the Brownback administration.
“To put that number into context, last year the State of Kansas spent $1.2 billion in state money on Medicaid,” Weisgrau said. “This increase of $625 million is over 10 years, but the Legislature decided we could not afford that.”
The administration's calculation, he said, did not include the offsetting costs to local programs — county health departments, safety-net clinics, hospitals — for covering the needs of the uninsured.
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.
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.
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.
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.
The state health department earlier this month stopped analyzing HIV tests for many of the state's medium and small counties and also stopped providing rapid or oral test kits, which is creating a new burden for cash-strapped health departments and creating some uncertainty whether they can continue testing for the disease in some rural locations around Kansas.
Compounding the problem, some local department heads said, was the short notice they received that the services previously provided free to them by the state were being terminated.
Notification letters from the Kansas Department of Health and Environment went out in late November, they said, giving them only about five weeks, including the holidays, to make alternate arrangements in time for Jan. 1, when the new policy kicked in.
"It's another nail," said Julia Hulsey, director of the Reno County Health Department in Hutchinson.
Kansas routinely ranks low nationally in its support for public health agencies.
New cost for patients
Hulsey said her department was able to contract with a laboratory in Wichita that agreed to provide the testing supplies for free (though it will charge for the lab work) and so her agency plans to continue the tests but will start charging patients for them probably by Feb. 1, once she has a clear picture of her agency's new, added costs.
"I don't have that whole cost figured out yet," Hulsey said, "but, of course, it will be more than KDHE because they didn't charge for it."
She said her goal would be to price the tests as low as possible to not discourage people from getting them. She said the department historically has performed about 220 tests a year.
Dan Partridge, director of the Lawrence-Douglas County Health Department, said Lawrence Memorial Hospital agreed to help with the testing after KDHE withdrew the services, so it will only cost his agency about $9,000 a year to continue the testing instead of about $18,000. But he said the new obligation signals another state retreat from support for local health departments.
Urged to continue
State officials, in their November letter, urged the local departments to try to continue the services on their own.
KDHE "would like to encourage your agency to continue to provide HIV testing to clients requesting an HIV test, especially those reporting high-risk behaviors," the letter stated. "However, any test conducted at your agency beginning January 1, 2013, and continuing thereafter will need to be paid for by either your agency or by the client through insurance, public assistance programs, or out-of-pocket."
But a spokesperson for the state's local health departments said it would be difficult or impossible for some smaller departments to pay for the tests on their own.
"I suspect there will be some health departments in some areas that won't be able to find a workaround like Douglas County," said Michelle Ponce, executive director of the Kansas Association of Local Health Departments. "I couldn't give you a firm number, but in some of those rural areas they may not have another option for testing."
The state’s letter also included some cost-comparison information to help the local departments shop for testing materials, lab work and other necessities of the program.
Hulsey in Reno County said she ended up considering four or five outside laboratories between the time she got the letter and Jan. 1 when the state assistance stopped.
"We got very short notice on this," she said. "And then having to go negotiate for ourselves...you never know if you're getting the best price."
State officials said they had to reduce the services because of cutbacks in a federal testing program administered by the Centers for Disease Control and Prevention that has been reconfigured to focus on areas where the incidence of HIV/AIDS is greatest.
In the past, according to state officials, 40 local health departments received the free services. That number has been trimmed to 10, according to Ralph Wilmoth, director of the HIV/AIDS program at KDHE. The 10 county health departments that will continue to get the aid include Johnson, Sedgwick, Wyandotte and Shawnee, the state’s most heavily populated, and also Crawford, Pratt, Riley, Saline, Thomas and Trego counties.
The state also will provide the testing services to various organizations other than health departments in about a dozen counties. For example, in Douglas County the services will be continued for the Douglas County Aids Project, a non-profit group. In Reno County, the services will continue for the state prison in Hutchinson.
Wilmoth said the CDC made the program changes in anticipation of the full-scale implementation of the Affordable Care Act, which begins Jan. 1, 2014. Millions of Americans are expected to become newly eligible for Medicaid then and HIV testing is among the health services covered by Medicaid.
Linked to Medicaid expansion
But when the U.S. Supreme Court ruled on the health reform law, it concluded that each state had the option to not expand its Medicaid eligibility and Gov. Sam Brownback nor the Kansas Legislature have yet determined whether Kansas will broaden access to its program, which is known as KanCare.
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.
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.
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.
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.
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.’”
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.
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.
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.
A range of political and economic uncertainties are hindering the ability of hospital officials to plan for the future, according to a report released today by the Kansas Hospital Association.
"The 2012 election has moved the health care debate to the forefront, which is good," the association's chief executive Tom Bell wrote in an editorial accompanying the report. "However, the ongoing nature of the debate complicates hospitals’ ability to make investments."
Among the unknowns cited in the 16-page report:
• The impact of the 2012 election on Medicare reform and on implementation of the Affordable Care Act,
• The uncertain future for federal disproportionate share payments, which compensate hospitals for treating uninsured patients who do not pay, and
• Whether Kansas will expand Medicaid eligibility as provided for under the ACA.
"Cuts to entitlements, especially significant federal cuts to Medicare, could jeopardize hospitals and physicians — limiting access to care," Bell said. "The state’s pending decisions about Medicaid expansion also will have a substantial impact, at a time when hospitals have already surrendered significant Medicare revenue through the ACA with the expectation of expanded coverage."
Under the health reform law, about 130,000 additional Kansans are expected to become eligible for Medicaid in 2014. The state currently has about 350,000 people directly benefiting from Medicaid services. In anticipation that hospitals would be providing less uncompensated care to uninsured patients because of expanded Medicaid eligibility, the ACA also reduced the disproportionate share payments.
While the U.S. Supreme Court ruled much of the health reform law constitutional, its decision granted states leeway to decide if they will expand eligibility.
If Kansas opts not to expand its Medicaid coverage, Bell has 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.
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.
"Decisions regarding the expansion of Medicaid under Obamacare will not be made until after the November elections. The Brownback administration does not speculate on hypotheticals," according to a statement issued by the Governor's Office.
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.
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.
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:
In Pittsburg, the community health center so desperately needed more space that last year staff converted closets and a bathroom into offices.
But next year the number of patients the center sees is expected to grow 24 percent, said Krista Postai, chief executive of the Community Health Center of Southeast Kansas.
"And I have no place to put them," she said. "This building is totally and completely at capacity."
That should soon change.
By December 2014, using a $4.7 million federal grant, the center will nearly triple its space from 15,000 to 40,000 square feet.
The grant was announced today by the U.S. Department of Health and Human Services. It is part of more than $21.6 million awarded to five Kansas community health centers.
About 40,000 new patients will gain access to care thanks to the construction and renovation projects funded by the grants, according to HHS.
The funding stems from the Affordable Care Act, which authorized $9.5 billion to expand health services over five years and $1.5 billion for construction and renovation at community health centers.
“For many Americans, community health centers are the major source of care that ranges from prevention to treatment of chronic diseases," HHS Secretary Kathleen Sebelius said in a prepared statement. "This investment will expand our ability to provide high-quality care to millions of people while supporting good paying jobs in communities across the country.”
The grant amounts for the other Kansas health centers were:
■ $2.7 million for the Salina Family Healthcare Center in Salina.
■ $4.6 million for Hunter Health Clinic in Wichita.
■ $4.5 million for Konza Prairie Community Health Center in Junction City.
■ $5 million for PrairieStar Health Center in Hutchinson.
The grant funds were disbursed directly to the health centers, which are private, nonprofit organizations.
In Pittsburg, the new construction is set to begin in July and finish by December 2014, Postai said.
The center will then be able to expand most existing services as well as add optometry, physical therapy and speech therapy services. An estimated 8,200 additional patients will be able to access the center.
Plans are to add 42 positions at an average salary of $45,700 as a result of the expansion, center officials said.
The waiting room has been at capacity for years with more demand on it after one of the area's biggest employers was shuttered at the end of 2008. The wheel maker Superior closed as the auto industry crashed and the number of people near Pittsburg without insurance shot up from 12 percent in 2009 to nearly 18 percent in 2010.
"From the time we open, it is wall-to-wall people. We need space," Postai said. "You can only be open so many hours and you can only schedule so creatively. And our efficiency has been impacted by our lack of space."