A MEDICAID EXPANSION ROUND-UP

Throughout the 2016 Presidential campaign and not long after entering office, President Trump was set on repealing the ACA's provisions for Medicaid expansion. As a matter of fact, President Trump and the supervisor of The Centers for Medicare and Medicaid Services (CMS), Seema Verma, are presently considering waivers to the Medicaid program that the prior administration rejected. In spite of the Trump administrations unsuccessful efforts to reform Medicaid on the federal level, a number of states are making attempts to expand their programs. Below is a summary of states in varying stages of expansion discussions.

STATES CONSIDERING MEDICAID EXPANSION

Nebraska: Within the past six years, any attempts to expand Nebraska's Medicaid program have failed as a result of Republican leadership. Republican Governors, Pete Ricketts and his predecessor Dave Heineman both argued that the state could not afford to expand Medicaid. Additionally, they think that expanding Medicaid would favor able-bodied citizens instead of low-income residents, for whom the program was designed.

Nonetheless, that may all shift this November at the voting booths. Currently, there are a number of healthcare associations and advocacy groups in the process of collecting signatures from locals to secure a proposal under the Insure the Good Life Petition. Having noticed the success of Maine's ballot initiative, supporters in Nebraska are building up confidence that they will produce a similar result. In order for the proposal to be included on the ballot, a total of 85,000 signatures from registered voters are needed by July 6, 2018. According to Insure the Good Life coordinators, people have been receptive to the idea of expanding Medicaid.

Idaho: Even with resistance from the Republican-leaning legislature, Idaho activists are seeking to expand their Medicaid program to 78,000 residents under the ACA using a ballot initiative. Expanding the program would serve to cover Idahoans who fall into a coverage gap because they make too much money to be eligible for Medicaid but not enough to be given subsidized health insurance in the exchange.

In order to get on the November 6th ballot, advocacy groups had to secure at least 56,192 signatures from 18 districts around the state by May 1, 2018. The advocacy groups filed the signatures before the deadline and claim they have the required threshold needed to land a place on November's ballot. At this point, the signatures will need to be verified by county clerks before June 30th, in order for the expansion proposal to be voted on.

While hopes are high among advocates, implementation of expansion will fall on the governor and state lawmakers; additionally, they have the power to reverse voter-passed initiatives. Republican candidate, Rep. Raul Labrador will resist the expansion initiative if he is elected. According to Labrador," I think that they need to be informed about what Medicaid expansion would do for the state. If you look at every single state that has expanded Medicaid, they're spending more money than they expected to spend ... and that's taking away money from all the other needs."

Utah: Despite having the available federal funding and the states Republican Governor, Gary Herbert's (R - UT) support of Medicaid expansion, there has been enough resistance from the state legislature in Utah to prevent any expansion momentum. Advocates of expanding Medicaid in Utah pushed back by passing a ballot initiative similar to Maine's.

Aside from that, Governor Herbert also signed the HB472 bill. The bill seeks authorization from the federal government to expand his states Medicaid program to 100% of the federal poverty level (FPL) while also implementing work requirements in order to deal with the coverage gap. Expanding that states program to 100% of the FPL would extend coverage to 72,000 residents by 2020 instead of 150,000 under 138% FPL. If the bill successfully passes, Utah's out of pocket costs would be far less than if their program expanded to 138% FPL.

Arkansas submitted a similar plan that would have capped eligibility at poverty level instead of 138% of the FPL. CMS did not approve the request and it is not likely that CMS will endorse the governor's bill since the federal government has only approved these types of requests under the stipulation that states expand to 138% of the FPL.

While the governor's administration would like to receive approval for the bill, Utah voters will also have a chance to weigh in at the ballot boxes in November to fully expand Medicaid to the 138% FPL.

Virginia: In February, The Virginia House of Delegates voted and approved a budget accepting ACA Medicaid expansion in conjunction with work requirements for enrollees. However, Virginia's Senate budget did not incorporate arrangements for expansion. Due to the split support for Medicaid expansion, the Virginia legislature was unable to settle a budget. Consequently, the implementation of Medicaid expansion and Virginia's FY 2019 budget are currently deadlocked. It has been close to two months since Virginia's General Assembly adjourned without consensus.

On May 14th, the Senate met for a special session to discuss a spending plan and the Senate Finance Committee will proceed with work on the budget today. The entire Senate will reconvene on May 22. In order for Virginia to expand its Medicaid program, there will need to be a majority vote in both the House and Senate. If Virginia administrators cannot come to an agreement by June 30th, the state could experience its first government shutdown.

MAINE HAS ADOPTED MEDICAID EXPANSION BUT IS IN LEGISLATIVE DEADLOCK

Maine's Medicaid program, MainCare, was authorized for expansion last November through a ballot initiative. Voters advocated the expansion by 59%. Nevertheless, for 80,000 low-income residents who would have been eligible for coverage, the state missed the state plan amendment submission deadline to CMS (April 3, 2018). Maine's legislature is presently facing a deadlock due to Governor LePage's (R) resistance to expansion.

After the vote, the governor declared, "this fiscally irresponsible Medicaid expansion will be ruinous to Maine's budget."

Under the law, it is estimated that Maine would spend $55,000,000 annually on the program and the federal government would cover at least 90% of the cost of MainCare's new enrollees. LePage says that the cost of the expansion is twice the amount estimated by the state legislature and refuses to implement the plan unless his requirements are met.

LePage's stipulations consist of:

• That taxes will not increase
• Stabilization money funds won't be used
• The funding mechanism will be ongoing
• Waiting lists for the disabled and elderly are fulfilled before Medicaid eligibility expansion.

Due to Governor LePage's resistance, Maine Equal Justice Partners (MEJP) has submitted a lawsuit against DHHS for failure to act. MEJP argues that the administration is denying residents coverage that is required by law. They are afraid that an estimated 70,000 low-income residents seeking coverage will not be able to enroll by the next deadline, July 2, 2018. Maine's State Attorney General, Janet Mills, declined to represent the governor in the case. However, she did permit LePage's request to seek outside counsel for representation in the case.

The landscape of Medicaid is changing as reformists submit waivers and introduce work requirements. Additionally, Republican leadership across the country is resisting Medicaid expansion, strongly believing that it goes against the programs original objective. Despite the GOP's opposition, there is a significant amount of activity amongst expansion supporters to expand their state's Medicaid programs. Through ballot initiatives, voters are stepping out in front of their legislatures to voice their support for expansion at the polls this coming fall.

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