AN UPDATE ON MEDICAID EXPANSION - IDAHO, NEBRASKA, UTAH, MAINE & VIRGINIA

Support for Medicaid expansion is on the rise as states move toward general elections this fall. Supporters of expansion have been busy in recent months as they aim to expand their programs through ballot initiatives. In May we reviewed a number of states considering expansion. Here is an up-date on their progress:

NEBRASKA

Nebraska has not been able to expand Medicaid for the previous seven years and the latest legislative effort, Legislative Resolution 281CA, is in gridlock between lawmakers. However, in March, Senator Morfeld backed a petition that would give citizens the opportunity to vote on the issue. Under the Insure the Good Life petition, 84,268 valid signatures were needed by July 6th in order to have the issue on November's ballot. The ballot initiative would extend coverage to 90,000 Nebraskans.

The petition effort exceeded the required amount of signatures with 133,000 submitted for review. While this boosted the outlook of expansion supporters, it has been countered by an attempt to block the petition. Two Republican lawmakers, Senators Lydia Brasch and Mark Christensen, have filed a lawsuit against the effort. The senators are worried about the negative effects it could have on taxes and also it's impact on existing coverage.

The proposal would expand coverage to single adults and couples without minor children that are not eligible for Medicaid presently. In addition, parents and disabled individuals whose income is up to 138% of the poverty level would be covered. Over an 8-year period, it's estimated that the expansion would cost Nebraska $100 million per year.

Meg Mandy, campaign manager for Insure the Good Life, denounced the lawsuit calling it, "a desperate attempt to block the people's ability to voice their opinion on this issue and ensure affordable health care for 90,000 Nebraskans." According to Mandy, these are "two politicians who have failed to find solutions for working Nebraskans to access health care."

IDAHO

Idaho's ballot initiative, Reclaim Idaho, strongly believes that expansion will save taxpayers money and aims to expand coverage to 62,000 citizens. Advocates of the initiative contend that the 62,000 individuals are in a coverage gap between Medicaid and insurance on the state exchange. They are either making too much money to receive Medicaid or not enough in order to secure insurance on the state exchange.

On July 17th, the initiative paid off and Idaho's Secretary of State, Lawerence Denney, verified that the ballot initiative had obtained enough signatures in order to have Medicaid expansion on November's general election ballot.

The initiative looks to extend coverage for those who are not otherwise eligible for any other coverage under the state plan. If passed, Medicaid eligibility will expand to include people under 65 whose modified adjusted gross income is 133% of the federal poverty level or below.

At the start of August, a number of Republicans began to show support for the initiative. Among the advocates was the chairman of the State's Legislature House Health and Welfare Committee, Fred Wood (R). He announced his endorsement for the initiative and told Times-News, "The Legislature's been struggling with this problem for years." The chairman believes that it is the best solution for the uninsured population within the coverage gap.

UTAH

Medicaid expansion is being pursued by two separate fronts in Utah. While advocacy groups are going after expansion through a ballot initiative, Governor Herbert has signed a bill asking for partial expansion from the federal government.

Bill HB472 would expand the state's Medicaid program under the stipulation that it would only expand to 100% of the Federal Poverty Level (FPL), instead of the federal mandate of 138%. By 2020, 72,000 residents would be eligible for coverage and the out of pocket expenses would be far less under the bill.

According to The New York Times, CMS is no longer considering Utah's partial expansion. However, that may change after the midterm elections.

On the ballot initiative front, Utah Decides obtained the required signatures in order to have expansion on the November 6th ballot. If approved by voters, the expansion would increase coverage to 138% of the FPL. That equates to almost $17,000 a person, or $34,000 for a family of four. It's estimated by organizers that an additional 150,000 adults would gain eligibility as a result of the expansion.

VIRGINIA

After almost 6 years of resistance from Republican legislators, Virginia voted in favor of Medicaid expansion under the ACA on May 30th, 2018. The provision to expand the state's Medicaid program to more than 400,000 Virginia residents was included in the General Assembly's approved budget. However, it came at a cost. Republicans only accepted the expansion under the condition that it would incorporate a 20-hour-a-week work requirement.

As Virginia prepares for Medicaid expansion there may be additional barriers ahead, postponing and possibly preventing the increased coverage. Critics consider the work requirement to be a violation of the law because it could possibly block a person from access to healthcare. They argue that many of the people that would be eligible for coverage under expansion would have to choose between working more hours and healthcare.

Regardless of the controversy over work requirements, government officials are confident that Medicaid will expand this coming year whether or not the requirements are enacted.

MAINE

Last November, Maine's Medicaid program received support for expansion after 59% of voters supported it through a ballot initiative. Despite its approval, the state's Governor, Paul LePage opposed the initiative and placed expansion in a legislative deadlock.

Governor LePage is concerned over the financial strain that expansion would put on the state. The governor stated, "this fiscally irresponsible Medicaid expansion will be ruinous to Maine's budget."

Shortly thereafter, Maine Equal Justice Partners submitted a lawsuit against DHHS for the failure to act and refuse residents coverage. MEJP asserts that the governor is denying newly eligible applicants coverage that is mandated by law. After evaluation, a Superior Court judge ruled in favor of MEJP; however, the state's administration is appealing the judgment. Presently, a decision on the matter is pending in Maine's Supreme Judicial Court.

At the moment, expansion is still in deadlock but that has not prevented citizens from applying for coverage. Additionally, the LePage administration and Maine's Department of Health and Human Services is promptly rejecting these applications. Despite the rejection of applications by the LePage administration, MEJP is instructing people to continue applying for Medicaid.

Nearly 80,000 low-income citizens would be eligible for Medicaid coverage as a result of the expansion. This number includes parents that were not formerly eligible and childless adults.

When asked about the status of expansion, DHHS has declined to comment due to the pending lawsuit. The state could end up spending nearly $200,000 for a lawyer to defend the LePage administration.

Regardless of the Trump administration's attempts to reform Medicaid on the federal level, a number of states are going after Medicaid expansion by carrying out ballot initiatives. These efforts are enabling voters to step out in front of their legislatures and voice their support for expansion at the polls this fall.

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MEDICAID EXPANSION HAS IMPROVED THE ACCESS TO QUALITY CARE

While Medicaid expansion supporters are encouraged by the most recent developments in Maine and Virginia, there are concerns about the access to quality care as the Medicaid population expands. To answer these questions, a number of studies have been conducted to help assist the states considering expansion and those that are making adjustments to their current programs.

Medicaid Expansion And Rural Areas

Since the majority of the rural populations are below the poverty line and uninsured, rural areas across the nation rely on community health centers for primary care. The increased federal funding from the Affordable Care Act and Medicaid expansion were thought to be solutions for improving the access and quality of care for these communities.

In a report from Health Affairs titled, Medicaid Expansion And Community Health Centers: Care Quality And Service Use Increased For Rural Patients, analysts looked into the changes in quality and access between 2011 and 2015. After comparing community health centers from states that expanded with centers in states that did not, the report indicated that patients covered by Medicaid rose to 13% and uninsured patients decreased by 11%.

Researchers also reviewed urban centers from areas that expanded Medicaid with urban centers in areas that did not, but the study did not discover any notable changes to the quality of care.

As opposed to the urban community health centers, rural centers from states that expanded Medicaid saw substantial improvement. Researches strongly believe that these improvements may be a result of more affordable prescriptions under Medicaid or perhaps as a result of the fact that insurance access to care makes visits to health professionals less costly.

Are More Conservative Versions of Medicaid Working?

Health Indiana Plan 2.0 was the outcome of the state expanding Medicaid by way of the 1115 waiver process. In order to qualify, program enrollees are required to contribute to a health savings account. Any time an enrollee fails to make a payment, their benefits are reduced. Furthermore, enrollees that make more than the poverty line are locked out of coverage for 6 months if they miss a payment.

Indiana University explored the effects of the state's decision and compared it to other states that expanded. Using data from the American Community Survey, analysts aimed to see if adults between the ages of 18 and 64 had insurance coverage or Medicaid coverage from 2009 to 2016. According to their analysis, states that expanded their Medicaid programs saw greater gains in comparison to states that did not. Generally, states that had higher insurance coverage rates before expanding saw more gains. Out of 27 states, Indiana ranked in the middle at 13.

Regardless of Indiana's additional conditions for coverage, the state experienced notable Medicaid coverage gains. Whether or not the gains could have been larger without the requirements could not be determined. Also, Indiana's cost-sharing requirements may be the reason for the state's underperformance.

A 30,000 Foot View Of Medicaid After Expansion

From the start of Medicaid expansion, there have been 77 research studies released with 440 unique analyses. More than half of the studies indicate that the effects of Medicaid expansion are in line with the goals of the Affordable Care Act. 35% of the studies showed no significant discoveries and 4% discovered a negative effect after expanding Medicaid.

Up to this point, the studies that have been carried out show that the effects of Medicaid expansion have been positive. The lead author of Indiana University's study, The Effects Of Medicaid Expansion Under The ACA: A Systematic Review, Olena Mazurenko says "With dozens of scientific analyses spanning multiple years, the best evidence we currently have suggests that Medicaid expansion greatly improved access to care, generally improved quality of care, and to a lesser degree, positively affected people's health."

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TRUMP ADMINISTRATION INDICATING POTENTIAL LIMITS TO MEDICAID 1115 WAIVER APPROVALS

From the very start of Donald Trump's presidency, he has vowed to grant states the flexibility they need to design their own Medicaid policies. HHS, collaborating with governors and state legislatures, could make dramatic state-by-state modifications to Medicaid using section 1115 waivers allowed under federal law.

Section 1115 waivers give states the possibility to forgo key provisions of federal Medicaid law. The changes made possible by Section 1115 waivers are not as dramatic as those featured in the failed bills. For example, states cannot use 1115 waivers to fully restructure Medicaid under block grants or per capita caps, neither can the federal government use them to eliminate federal reimbursements for Medicaid expansion; however, they are still significant.

Under the President Trump's administration, CMS has authorized 1115 waivers that the former administration consistently rejected. Many states, for instance, have been allowed to make employment a condition for Medicaid enrollment. (The state of Kentucky; however, is presently in court proceedings over the new policy.).

Trump's administration is likewise allowing Kentucky to require beneficiaries to report income changes while Arkansas is disenrolling beneficiaries for the remainder of the calendar year if they do not comply with the work requirement.

The list below is what CMS has previously declined, as well as what is still under deliberations:

MEDICAID 1115 WAIVERS THAT HAVE BEEN REJECTED BY CMS

Lifetime limits

In May, CMS rejected an 1115 waiver application from Kansas to set up a three-year time limit for people enrolled in the Medicaid program.

Joan Alker, executive director of the Center for Children and Families at Georgetown University, said in a statement that she was "... pleasantly surprised by that."

Utah, Wisconsin and Arizona have also sent similar 1115 waiver applications to CMS for lifetime limits, which Alker anticipates will also get rejected.

In a statement by Seema Verma concerning Kentucky's attempt to sanction lifetime limits on Medicaid enrollees, she stated "We seek to create a pathway out of poverty, but we also understand that people's circumstances change, and we must ensure that our programs are sustainable and available to them when they need and qualify for them."

Partial expansion

CMS rejected Arkansas' bid to decrease the number of people who qualify for the state's Medicaid program. Arkansas was looking to reduce the eligibility requirement from 138 percent of the federal poverty to 100 percent; however, it was not a firm denial, rather, CMS stated it could not back the waiver application "at this time."

Whenever states vote to expand Medicaid the federal government pays 90 to 100 percent of the program's expenses. If Arkansas were permitted to simply cover people up to 100 percent of poverty, the formerly enrolled members who lose their Medicaid coverage would be eligible for federal health insurance subsidies. This would shift the liability to pay healthcare expenses from the state to the federal government. This scenario is most likely not attractive to the Trump administration.

OTHER 1115 WAIVERS CURRENTLY PENDING

Work requirements for non-expansion states

Besides the denial of permitting lifetime limits on Medicaid enrollees, an additional component of Kansas' 1115 waiver application is still pending; namely, a work requirement. But unlike Arkansas, Indiana and Kentucky, Kansas didn't expand Medicaid by way of the Affordable Care Act (ACA); so demanding individuals to maintain an employment (minimally 80-hours per week) would most likely exclude them for the state's Medicaid program since they would be making too much money.

Oklahoma, Alabama, South Dakota and Mississippi are other states that didn't expand under the ACA exploring work requirements. The Center on Budget and Policy Priorities issued a report that highlights the catch-22 of these proposals.

In the state of Mississippi, for example, a single parent can not earn over $370 per month to receive Medicaid. Nonetheless, if they acquired 20-hour per week employment at minimum wage, they would earn $580 a month, which is too much income to qualify for Medicaid.

"They will be complying with the work requirement but still lose coverage. You're in this situation that can't be fixed," says Jessica Schubel, a senior policy analyst for the Center on Budget and Policy Priorities.

CMS' Verma has stated that she is concerned about this "subsidy cliff" and wants to find a "pragmatic and empathetic" approach to work requirements and other new Medicaid initiatives.

Drug testing for Medicaid enrollment

Finally, last year Wisconsin was the first state to ask for authorization to drug test Medicaid applicants allowing the denial of enrollment if they test positive. Specialists say that there is no way to tell where the federal government will decide the issue. Having said that, CMS has indicated that they would advocate the use of Medicaid funds to cover neonatal abstinence syndrome (a withdrawal ailment that takes place when an infant is born with an opioid addiction from their mother's use during pregnancy). Medicaid experts say it is hypocritical for the federal government to cover babies with drug-related problems but not their parents.

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MEDICAID SCORECARD INTRODUCED BY CMS TO ASSESS PROGRAM'S ADMINISTRATION

The Center for Medicare and Medicaid Services recently released a Medicaid Scorecard to improve transparency and accountability. The scorecard contains care quality data from 2015 statistics provided by participating states, in addition to federally reported information. By combining this data, CMS and the states look to evaluate the performance of Medicaid plans, the program's administration, and outcomes. Any effort to improve efficiencies within the Medicaid program is met with unanimous support across the country; however, industry experts are concerned with the quality of the data used and the underlying purpose of the Medicaid Scorecard.

CMS's preliminary Medicaid scorecard intends to improve state and federal alignment, beneficiary health outcomes, and program administration. It functions to analyze how effectively states are delivering health services to their beneficiaries; at the same time, it takes a look at the timespan it takes for the federal government to authorize waiver requests from the states. The Medicaid Scorecard focuses on three particular areas of measurement:

• State Health System Performance measures "how states serve Medicaid and CHIP beneficiaries across key domains."

• State Administrative Accountability provides "insight into how states and the federal government work together to administer Medicaid and the Children's Health Insurance Program (CHIP).".

• Federal Administrative Accountability provides "insight into how the federal government and states work together to administer Medicaid and the Children's Health Insurance Program (CHIP).".

The Chief of CMS, Seema Verma, views the scorecard as a means of improved accessibility to Medicaid data and the program's care outcomes. Verma declared, "This is about bringing a level of transparency and accountability to the Medicaid program that we have never had before." Over time, CMS says it will make updates to the Medicaid Scorecard enabling it to address additional issues.

The National Association of Medicaid Directors (NAMD) has raised concerns. According to NAMD, "There are significant methodological issues with the underlying data, including completeness, timeliness, and quality." They call into question the quality of the data and what conclusions can be made from it. In their point of view, the data itself is out of date, rendering it an unreliable source to identify a state's performance. Additionally, they point out that any determinations made from the scorecard will be problematic since it compares states with significantly different Medicaid structures.

The Association for Community Affiliated Plans (ACAP) is encouraged by the introduction of a Medicaid Scorecard but also recognizes inconsistencies. The groups CEO, Margaret Murray, sees CMS's initiative as a good start. Murray shared, "we agree with Administrator Verma's note that this is a beginning in terms of how we talk about quality, rather than an endpoint. For one thing, the draft scorecard brings into sharp relief the need for more uniform, consistent data reporting across the Medicaid program."

CMS has recently issued their Medicaid Scorecard with hopes to improve state and federal alignment, beneficiary health outcomes, and program administration; however, Industry experts are calling into question its methodology.

Discover more Medicaid news here.

VIRGINIA LEGISLATURE APPROVES MEDICAID EXPANSION, NOW EYES TURN TO UTAH, IDAHO, NEBRASKA AND MONTANA

After months of deliberation among Republican representatives in both the House and Senate, lawmakers in Virginia voted in support of Medicaid expansion under the ACA on May 30th, 2018. The provision to expand the state's Medicaid program to over 400,000 Virginia citizens was included in the General Assembly's approved budget. Democratic Governor, Ralph Northam signed the bill at the state's capital on June 7th. Virginia will fund the expansion with the aid of a 90% funding from the federal government. According to The Commonwealth Institute, "The new Medicaid coverage would require state contributions totaling $1.02 billion over eight years, resulting in a net savings to the state of $1.06 billion."

The ruling to expand was motivated by two contributing factors. First and foremost, last November, the Republicans were at risk of losing their majority rule due to their resistance to Medicaid expansion. Second, Virginia's growing uninsured population is a strain on the state's ability to provide healthcare to its residents. Since the Affordable Care Act was introduced, the uninsured population has expanded as a result of increasing costs for coverage. Proponents feel that Medicaid expansion will strengthen Virginia's health care system and benefit both program members and people with private insurance. However, critics are worried about the related costs and sustainability of expanding the program.

The vote for Medicaid expansion in Virginia is encouraging news for supporters of other states around the country looking to expand their programs. At the moment, there are four states debating the issue.

Utah - In spite of support from lawmakers for a partial expansion, activists in Utah pulled together the required number of signatures to have a full expansion of Medicaid on the state's November ballot. At this time, polls suggest that over half of the state's voters back expansion.

Idaho - According to healthcare advocates, activists in Idaho have accumulated the required signatures for a ballot initiative. The initiative would allow residents to vote in November on a expansion of the states Medicaid program. At the time of this post, the signatures have been submitted to county clerk's for confirmation by June 30th.

Nebraska - Supporters of expansion in Nebraska have been collecting signatures since April for the Insure the Good Life petition. They will need 85,000 signatures from registered voters by July 5th in order to vote on the matter in November's general election. According to groups collecting signatures, momentum is on the side of Medicaid expansion for Nebraska.

Montana - Montana's Medicaid program is wanting to extend their expansion since it is set to expire in 2019. In order to fund the expansion, a ballot initiative requiring 25,000 signatures has been authorized by the Secretary of State. Unlike other efforts, Montana proposes an increase on taxing tobacco by $2.00 a pack alongside a 33% increase of the wholesale price for tobacco products. At this time, proponents are promoting the initiative and securing signatures.

As Virginia neared its first government shutdown, recently legislatures finalized a state budget that incorporated Medicaid expansion. 400,000 residents will now be eligible to enroll in the program. The choice to expand the program, despite resistance from Republican leadership, could be a good indication as to what will occur in other states seeking to expand this year.

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STATES PLAN TO USE MEDICAID 1115 WAIVERS TO WAIVE KEY PROVISIONS OF THE PROGRAM

The repeal of the Affordable Care Act with its existing provisions for Medicaid did not materialize at the national level in 2017; nevertheless, states are looking into reform independently by way of Medicaid 1115 waivers. These waivers concentrate on priorities within the states and allow local governments the flexibility to test coverage models that do not reflect program rules of the federal government.

Medicaid 1115 waivers provide states the opportunity to waive key provisions of federal law. The changes made possible by Section 1115 waivers are not as dramatic as those included in the failed bills-- for instance, states cannot use these waivers to fully restructure Medicaid under block grants or per capita caps, neither can the federal government use them to take away federal reimbursements for Medicaid expansion-- yet they are still significant.

In an attempt to "support states helping Medicaid beneficiaries improve well-being and achieve self-sufficiency", CMS released new guidance for waivers that imposed work requirements on January 11, 2018. Along with work requirements, states are also looking into provisions such as eligibility time limits, drug testing, and premiums. Because of this, these waivers are controversial and have brought up policy issues throughout the country.

At the moment, a number of states have submitted waivers for approval from the federal government. Here is some of the highlighting waiver activity within the states.

NEW HAMPSHIRE'S MEDICAID 1115 WAIVER FOR WORK REQUIREMENTS

New Hampshire was the fourth state to be permitted by the Trump administration for Medicaid work requirements. Under the state's Medicaid 1115 waiver, able-bodied adults will either need to work, develop job skills, or be involved in community service in order to receive premium assistance and program benefits from the state's Medicaid expansion.

Chief of CMS, Seema Verma congratulated the state and pointed out, "the Trump Administration has helped create one of the strongest job markets in our nation's history and we want to make sure able-bodied, working-age adults receive the necessary skills to join our growing workforce."

Governor Chris Sununu (R-- NH) said, "Work requirements help lift able-bodied individuals out of poverty by empowering them with the dignity of work and self-reliability while also allowing states to control the costs of their Medicaid programs."

Critics of the waiver are concerned that its ramifications will not support the original goals of the Medicaid program. A number of Democratic lawmakers are in opposition to the work requirements, strongly believing that they undermine access to the healthcare program. Supporters of the waiver see it as means of safeguarding the program's sustainability. They assert that Medicaid should be reserved for the country's most vulnerable and low-income individuals and families.

KANSAS IS DENIED 1115 WAIVER FOR LIFETIME LIMITS

Support for Medicaid expansion in Kansas came to a halt in February despite efforts from the Senate Public Health and Welfare Committee and House Democrats. Kansas Governor, Sam Brownback (R) vetoed the bill. Had it been approved, an estimated 150,000 residents would have been eligible.

While expansion failed, Kansas is one of five states, including Utah, Maine, Arizona, and Wisconsin, to ask for lifetime limits from CMS. This would have made it possible for the state to restrict coverage to three years/36 months for some of its recipients. CMS has declined the request making Kansas the first of the five states requesting lifetime limits to be denied.

Verma defended the decision saying, "we seek to create a pathway out of poverty, but we also understand that people's circumstances change, and we must ensure that our programs are sustainable and available to them when they need and qualify for them."

MEDICAID REFORM IN KENTUCKY 

Kentucky was the very first state to get approval from CMS for an 1115 waiver (January 12, 2017). The waiver will implement work requirements, monthly premiums for low-income parents and expansion adults, dis-enrollment and coverage lockouts, the elimination of retroactive eligibility, the addition of deductible and incentive accounts, and waiving non-emergency medical transportation.

Kentucky's governor, Matt Bevin (R), plans to start the overhaul of the state's Medicaid program on July 1, 2018. It will begin in Campbell County and reach across the state over a period of six months. These changes will predominantly affect able-bodied beneficiaries with incomes up to 138% of the federal poverty level that obtained coverage during the program's expansion in 2014. Due to the overhaul, it's approximated that Kentucky and the federal government will save $2.2 billion over five years. Additionally, the Center On Budget and Policy Priorities expects that over the duration there will be a 15 percent drop in adult Medicaid enrollment.

On January 24, sixteen Kentucky Medicaid beneficiaries took legal action and sued the federal government over the waivers provisions. The group sees the Trump administration's approval as a violation of several federal laws and a threat to the lives of tens of thousands of low-income families.

HEALTHY INDIANA 2.0 CLAMPS DOWN ON ENROLLMENT AND ELIGIBILITY

CMS signed off on the amended extension of Healthy Indiana 2.0 on February 1. Initially, the state's waiver expanded the program under the Affordable Care Act (ACA) from February 2015 through January 2018 by changing the states pre-ACA limited coverage expansion waiver, Healthy Indiana Program 1.0. While other state's waivers focus on adults enrolled during expansion, Indiana's also includes changes to the terms of coverage for non-expansion adults. This encompasses low-income parents as well as those eligible for transitional medical assistance.

Healthy Indiana Program 2.0 features provisions such as: raising premiums by 50% for tobacco using members beginning the second year of enrollment, eligibility work requirements for most adults in 2019, dis-enrollment and coverage lockouts, introducing a tiered premium structure, and restricting transitional medical assistance eligibility to between 139% and 185% of the federal poverty level.

While there are a number of exemptions in place to help beneficiaries secure and keep coverage, the launch of these provisions will definitely alter program eligibility. Now that the state has received approval for their provisions, Indiana confronts the task of implementing them.

ARIZONA'S FOUR 1115 WAIVERS UNDER REVIEW 

Arizona is looking to update and reform their Medicaid program, Arizona Health Care Cost Containment System (AHCCCS). Currently, the state has pending Medicaid 1115 waivers with CMS. The amendments include a retroactive eligibility request, an Institution for Mental Disease (IMD) waiver, work requirements, and an uncompensated care payment model.

Originally, Arizona also requested for approval of a 5-year lifetime time limit on Medicaid enrollment. However, this was recently taken out from the state's requests after CMS turned down Kansas's similar request for a 3-year time limit. No other state at this time has lifetime limits. In regards to the decision to delay the lifetime limit request, Deputy Director of AHCCCS, Jami Snyder said, "We have removed the lifetime limit from the waiver request, really for the purpose of expediting approval of the work requirements request." Right now, Arizona is still in discussions with CMS.

Regardless of the federal government's inability to reform Medicaid, states are now taking action to do it themselves through submitting 1115 waiver requests to CMS. Around the nation, local governments are now taking into consideration provisions such as work requirements, drug testing, lifetime limits, and premiums. A few states have received approval while others are encountering strong resistance. While reform through Medicaid 1115 waivers is supported by many state legislators, the way in which they are carried out will be vital to ensuring the future of the Medicaid program.

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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.

Read more here.