Medicaid Expansion Funding Secured, Program to Continue

Governor Asa Hutchinson (R) signed an appropriation bill funding "Arkansas Works," the re-named State's Medicaid expansion, concluding a two-week-long negotiation that ended in a procedural maneuver to preserve the program's funding after the original appropriations bill failed to receive the required three-fourths majority vote to pass the Legislature. The State must now seek federal waiver approval to institute mandatory premium assistance for beneficiaries with access to cost-effective employer-sponsored insurance, a work referral program, and premiums for beneficiaries with incomes above 100% of FPL. The federal government has pledged to work with State officials to approve the waiver. Arkansas Works was passed during a special legislative session in which it was the only agenda item after Governor Hutchinson removed his Medicaid managed care plan from the agenda at the request of legislative leadership.


CMS to Assess Impact of Alternative Medicaid Expansion on Access to Care

CMS received expedited approval from the Office of Management and Budget to evaluate the impact of Indiana's alternative Medicaid expansion on beneficiaries' access to care, according to Modern Healthcare. Three beneficiary surveys will focus on the program's transportation benefit waiver, the application process, and the requirement that individuals with incomes from 100% to 138% of FPL contribute monthly to a health savings account or lose coverage. CMS requested this emergency approval so that the impact of the State's expansion program could "adequately inform" CMS's decision-making regarding Indiana's and other states' 1115 waivers, in particular the upcoming renewal process for Indiana's non-emergency medical transportation waiver, due December 1, 2016. After approving the State's waiver in 2015, which expanded Medicaid through a health savings account-like model, CMS contracted with a vendor to oversee the State's self-evaluation as well as two other contractors to conduct a separate evaluation. Governor Mike Pence (R) has expressed concerns about the objectivity and potential conflicts of interest among the federal vendors and that two independent evaluations may produce conflicting results.


Report Highlights State's ACA Implementation Successes

Kentucky's uninsured rate has been cut in half—to 8%—and Medicaid enrollment has nearly doubled since 2013, according to a report by the Kaiser Family Foundation that describes the State's ACA implementation as one of the most successful in the nation. The report credits Kentucky's ACA successes to: strong and engaged leadership; a high-functioning, integrated eligibility system for Medicaid and Marketplace determinations; broad outreach and enrollment efforts; State-specific branding; and strong access to care for Medicaid beneficiaries (access to care for qualified health plan enrollees has varied by plan). The report also highlights the State's lower-than-anticipated care costs for the Medicaid expansion population and overall cost savings generated by expansion. Additionally, the report reviews ongoing changes and potential implications, including the transition from kynect, the State-based Marketplace, to, and Governor Matt Bevin's (R) plan to make changes to the Medicaid expansion through a waiver. The report comes amid the troubled rollout of Benefind, the State's new online enrollment system for Medicaid and other public assistance programs, and the Legislature's failed efforts to preserve the Medicaid expansion and kynect.


Provider Opposition Stalls Medicaid Expansion Copay Proposals

Three bills to require copays for Medicaid expansion members, including a bipartisan proposal supported by Governor John Bel Edwards (D), were withdrawn from consideration during a hearing of the House Health and Welfare Committee following opposition testimony. The bill supported by Governor Edwards would have imposed an up to $8 per visit fee for non-emergency care in the emergency room and for "non-preferred" prescription drugs. Opposition to the proposals was led by the Louisiana Hospital Association, which released a statement indicating that Medicaid copays are "uncollectable" and a "huge administrative burden." Representative Jack McFarland (R) indicated after the hearing that he will bring the copay bill back up for consideration before the end of the legislative session.

Governor Testifies on Merits of Medicaid Expansion in State Senate

Governor John Bel Edwards (D) and Department of Health and Hospitals Secretary Rebekah Gee provided updated savings estimates and new operational details on the launch of Medicaid expansion at a Senate Health and Welfare Committee meeting last week. Governor Edwards and Gee told lawmakers that expansion will generate an estimated $677 million in savings over five years and approximately $1 billion over 10 years, in addition to the $184 million in anticipated savings for fiscal year 2017. These estimates are in stark contrast to former Governor Bobby Jindal's (R) estimates of $1.7 billion in costs over 10 years. The Medicaid agency's statement also highlighted plans to auto-enroll approximately 200,000 individuals who receive other State services and are Medicaid eligible in anticipation of a July 1 launch date.


Sixth Medicaid Expansion Veto Expected

The State Legislature approved Medicaid expansion for the sixth time this month, but not by sufficient margins to overturn Governor Paul LePage's (R) anticipated veto. The current proposal would cover individuals up to 100% of FPL through regular MaineCare (Medicaid) and provide subsidies for individuals between 100% and 138% of FPL to purchase qualified health plans on the Marketplace. The non-partisan legislative fiscal office estimated that approximately 80,000 adults would become eligible for coverage. Maine previously covered some childless adults up to 100% of FPL, but dropped this coverage in 2014, the year of Governor LePage's most recent Medicaid expansion veto.


Senate Rejects Medicaid Expansion for Fourth Consecutive Year

The Legislature voted 28-20 to remove LB 1032 from this year's legislative agenda, effectively rejecting a Medicaid expansion bill that would have provided healthcare coverage to an additional 77,000 residents. The bill proposed a three-year pilot program that would enroll the majority of expansion adults into qualified health plans on the Marketplace, excluding the medically frail and those with cost-effective employer sponsored insurance. Governor Pete Ricketts (R) and other opponents of the bill, including State Medicaid Director Calder Lynch, raised concerns about the bill's long-term costs, while supporters promised to continue their Medicaid expansion efforts next year.

New Hampshire

Governor Signs Bill Reauthorizing Medicaid Expansion

Governor Maggie Hassan (D) signed a bill renewing the State's Medicaid expansion program through 2018. The bill includes several new requirements for the program, which the State will seek a waiver to implement, including that enrollees be employed or engaged in a job search. However, the bill also includes a severability provision that would permit renewal of the program even if CMS does not approve some of the new requirements, including the work provision.


Draft Medicaid Waiver Released Requiring Contributions to the "Buckeye Account"

The Ohio Department of Medicaid released a draft 1115 waiver application describing the "Healthy Ohio Program," under which the State's pre-expansion Medicaid enrollees and the Medicaid expansion population would enroll in a high-deductible Medicaid managed care plan and receive a health savings-like account (the "Buckeye Account"), into which the State would deposit $1,000. Enrollees (with the exception of pregnant women) would be required to contribute the lesser of 2% of their income or $8.25 each month into their Buckeye Account, and would be disenrolled if they failed to do so after a 60-day grace period. Account funds would be used to pay the plan's copayments and deductible, and could be supplemented with incentive payments for meeting preventive care goals. Enrollees would be subject to an annual and lifetime benefit spending cap, which, if exceeded, triggers a transition to traditional managed care or fee-for-service coverage. Enrollees who become ineligible for the program due to an increase in income could apply their account balance to premiums or cost sharing for Marketplace or employer sponsored coverage.


Higher Costs, Less Access for Low-Income Residents Compared to Other Southern Expansion States

Low-income Texans are less able to afford their medical bills, to cover the costs of prescription drugs, and to access consistent care for chronic conditions compared to their counterparts in southern states that expanded Medicaid, according to The Commonwealth Fund. In addition to its decision to not expand Medicaid, Texas chose not to develop an in-person assistance program to help consumers enroll in insurance, and it passed laws limiting community organizations' ability to fill that role. The report also found that Texans had less awareness of the ACA's coverage expansions, lower application rates for Medicaid or Marketplace coverage, and lower rates of application assistance from navigators or social workers among those who applied for coverage. Five million, or nearly one in five Texans, are uninsured—the highest level in the country.

National News

Medicaid Expansion Improves Overall Financial Well-Being, New Report Finds

Medicaid expansion significantly reduced the number of unpaid non-medical bills and the amount of non-medical debt sent to third-party debt collectors, according to a report from the National Bureau of Economic Research. The report estimates that Medicaid expansion is associated with a reduction in collection balances by $600 to $1,000 per person and suggests that expansion populations may have better access to credit markets in the future than if they had not gained coverage. This is the first national study of expansion's effect on multiple measures of financial well-being, according to the authors.

Medicaid Expansion Is Improving Access to Care, According to Report

Individuals with incomes less than 138% of FPL in Medicaid expansion states were more likely to see a doctor, stay overnight in a hospital, and receive their first diagnoses of diabetes and high cholesterol than their counterparts in non-expansion states, according to an analysis of National Health Interview Survey data published in the Annals of Internal Medicine. This is the first evidence of increased healthcare utilization by low-income adults in expansion states, according to the researchers. The percentage of survey respondents who spoke with a doctor increased from 58% pre-expansion (2010 to 2013) to 68% post-expansion in expansion states, while there was no change in non-expansion states. Those who said they had no usual source of care due to costs fell from 13.3% to 6.6% in expansion states while that rate dropped "marginally" in non-expansion states. Despite improved access to care, enrollees did not have improved assessments of their own health, which the authors suggest may be because too little time has passed to allow for health improvements and because increased contact with providers and improved health awareness may negatively affect opinions about one's own health.

Expansion Enrollees Struggle to Pay Required Premiums, According to Report

While the vast majority of Medicaid expansion enrollees in states that impose premiums under 1115 waivers are exempt from paying those premiums due to their very low incomes, those who are not exempt are finding it difficult to make payments and are subject to penalties as a result, according to an analysis by Families USA. The report's authors also note that premium contributions collected across states do not cover the administrative expense required to maintain premium collection infrastructure.