Kansas bypasses Obamacare; will other states follow?

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Kansas' new law allowing the sale of health plans that can turn away people with pre-existing medical conditions has heightened concerns that more states may move to allow leaner, cheaper plans that don't comply with Affordable Care Act rules.

So far, three states have passed laws allowing their Farm Bureaus to bypass ACA rules and sell health plans that are free from any state insurance regulation. Kansas became the latest last week. The state's Democratic governor let the bill become law without her signature in the hope of winning GOP support for a bill to expand Medicaid to low-income adults, though that remains uncertain.

The move toward the skimpy plans comes despite strong public support for prohibiting insurers from discriminating against people with pre-existing conditions, and recent congressional Republican bills that would bar health insurers from doing so.

The Iowa Farm Bureau started selling unregulated plans last November, in partnership with Wellmark Blue Cross and Blue Shield, under a bill passed by state Republicans last spring. The Tennessee Farm Bureau Federation has been able to sell such plans since the 1990s. Neither Farm Bureau organization has reported how many people currently are enrolled in these plans.

Neither the Obama administration nor the Trump administration has taken any steps to require these plans to follow the federal insurance rules. Experts doubt any legal challenge would succeed because laws in those three states explicitly declare that Farm Bureau plans are not licensed or regulated as health insurance. Therefore, they likely are not subject to ACA requirements such as guaranteed issue and minimum essential benefits.

CMS Administrator Seema Verma gave a speech on Tuesday encouraging states to seek waivers easing the rules for the types of plans insurers can offer. 

Cheaper, skinnier plans that can use medical underwriting could destabilize the ACA market by siphoning healthier people away from ACA-compliant plans and driving up premiums, experts say.

"It may not be immediate, but it won't take long," said Sandy Praeger, a Republican and former Kansas insurance commissioner who opposed the bill. "The only way the Farm Bureau can sell cheaper policies is by limiting benefits and only insuring people who are low risk. This could spread to other states."

The stated purpose of the new Kansas law is to make cheaper coverage available to farm families whose incomes are too high to qualify for ACA premium subsidies, though any Kansas resident can pay the $45 to $65 membership fee and apply for coverage. The Farm Bureau claims its plans will be up to 30% to 50% cheaper than ACA exchange plans. It's estimated that 11,000 to 42,000 Kansans will be covered by the plans, said Ryan Flickner, the Kansas Farm Bureau's senior director of advocacy.

In letting the bill pass without her signature, Kansas Gov. Laura Kelly voiced "serious reservations" about it. 

"I believe it is fundamentally wrong to deny health coverage to anyone because they have a pre-existing condition," the Democrat said in a written statement. "It troubles me that only two other states in the nation have implemented a model similar to this bill, making the long-term impact uncertain."

Blue Cross and Blue Shield of Kansas and Minnesota-based Medica, which both sell exchange plans in Kansas, strongly opposed the Farm Bureau bill. Neither offered comment on the bill.

The Kansas Farm Bureau has not indicated what its new health plans will look like. Kansas Farm Bureau CEO Terry Holdren previously told lawmakers that premiums would be much cheaper mainly because the plans would be exempt from state and federal rules. The bill "would give us the ability to say no to folks if they don't meet our underwriting standards," he said.

But Flickner said the new Kansas plans likely will resemble those offered by the Iowa Farm Bureau, which allows anyone who pays the organization's annual dues to apply for coverage. The Kansas Farm Bureau and its third-party administrator will use medical underwriting to decide whom to cover and how much to charge, he added.

"We don't anticipate this will pull people from exchange," he said. "Our primary target audience is members we've been hearing from who are completely uninsured today, and some members who have gone on faith-based healthcare sharing programs."

In Iowa, applicants are asked if they have been treated in the past five years for any of 16 conditions, including diabetes; heart, lung, brain, blood or stomach issues; and mental health or addiction issues. There is a $3 million life cap on benefits for each member.

In addition, the Iowa Farm Bureau's outline of coverage states that monthly premiums may change midyear, based on changes in benefits and other factors. That's unlike standard, regulated health plans, whose premiums are locked in for the full benefit year.

"They can do whatever they want, and there will be no consumer protection," former insurance commissioner Praeger said. "That's going to be a shock to people. My guess is that people won't be fully informed when they buy these plans."

In neighboring Nebraska, the state Farm Bureau took a sharply different approach. It partnered with Medica to offer ACA-compliant plans solely to people involved in agriculture. No one can be denied coverage or charged more based on health status.

"The folks in Nebraska were facing the exact same challenge," said Dennis Maggart, president of the McInnes Maggart Consulting Group in Prairie Village, Kan. "But they didn't look for a legislative exclusion from insurance rules. They said we'll play by the same rules but just do it better. They hit the nail on the head."

Maggart is worried that the Kansas Farm Bureau plans will peel off younger, healthier people and sharply drive up premiums for ACA-compliant plans. He sees evidence of that in Iowa. There the monthly premium for a silver benchmark plan for a 40-year-old nonsmoker rose from $379 in 2017 to $713 in 2018 and $762 in 2019. 

"Why emulate something that's not working as well as what we're doing here in Kansas," he said. "It's going to be devastating to the exchange."

Praeger fears that the very people whom Kansas lawmakers intended to help will be denied coverage. The Iowa Farm Bureau itself cited a case where a couple who had been paying premiums of more than $2,700 a month for an ACA plan were able to buy a Farm Bureau plan for just $626 a month—except the wife didn't qualify based on pre-existing medical conditions.

"What kind of deal is that?" Praeger said. "It just won't work."

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(Montana) Hospitals prep for Medicaid funding cuts

Hospitals across Montana are preparing for a decrease in Medicaid funding through layoffs and program “realignments” as the fallout from last year’s state budget shortfall continues to land on Montana’s health care providers.

The cuts are coming to Montana’s Medicaid reimbursement rate, which provides hospitals with funding to serve patients on the federal health care program. It’s part of an attempt by the Montana Department of Health and Human Services to address the $49 million in cuts assigned to the department last fall in a special state legislative session following a statewide budget shortfall of $227 million.

Medicaid — the program which combines federal and state funds to provide coverage to people who can’t afford health insurance or nursing home care — was expanded in Montana under the Affordable Care Act in 2016.

Kalispell Regional Healthcare is expected to lose $6.6 million in Medicaid funding this year, and has begun to address the funding gap through staff layoffs in recent weeks. Kalispell Regional Communications Director Mellody Sharpton did not specify the number of layoffs but said that it was “considerably less than 1 percent” of those employed by the health system and that none were involved in direct patient care. Kalispell Regional employs over 4,000 people in Northwest Montana.

That $6.6 million loss will also land, in part, on North Valley Hospital in Whitefish, which has been under the Kalispell Regional umbrella since an affiliation in 2016. North Valley Community Relations Manager Allison Linville said she had no additional information on layoffs or potential staff changes at the hospital.

Statewide, hospitals in Montana have also been strained by the reimbursement cuts. The Bozeman Daily Chronicle reported last week that Bozeman Health expects a $2.6 million cut in reimbursements and will absorb the loss without cutting services or staff. Instead, they will attempt to recoup the difference by saving money on supplies such as medications or equipment.

Community Medical Center in Missoula announced Friday that it was eliminating 16 staff positions in response to the cuts, which they said would decrease its funding by more than $6 million in 2018.
More changes could be forthcoming if Montana’s Medicaid expansion is not renewed in next year’s meeting of the state Legislature. The 2-year-old program, which expanded Medicaid under the Affordable Care Act, now enrolls over 94,000 Montanans — nearly one in 10 residents.

The program has cost $802 million during its first two years. The state of Montana has paid for 5 percent of that number, while the federal government contributed the other 95 percent.

A recent report by the Montana Healthcare Foundation predicted that the program could pay for itself by generating $350 million to $400 million of new spending in Montana’s economy between 2018 and 2020. According to the report, the Medicaid expansion injects money into Montana’s economy by supporting new health care spending, shifting the cost of Medicaid care from providers to the federal government and promoting economic activity, such as 5,000 jobs and $270 million in personal income by 2020.

As of now, the expansion is set to expire next year.

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Medicaid Is Great, but Rural Maine Needs Hospitals, Too

LEWISTON, Me. — This week Maine voted to become the 32nd state to expand Medicaid despite opposition by Gov. Paul LePage, who had vetoed five previous expansion bills passed by the state legislature and has now threatened to block the results of the ballot initiative. Unless Mr. LePage succeeds, about 80,000 more Mainers will be eligible for coverage, a victory in an unsettling year for health care in America.

With the Affordable Care Act under constant threat from the Trump administration and out-of-pocket costs rising faster than wages, health care topped the list of the most important issues facing Americans this year.

However, Maine and other rural states face a health care crisis that Medicaid expansion can’t fix on its own. It’s not about affordable coverage; it’s about access: For too many rural areas, doctors and hospitals are scarce.

In the postwar era, America made hospital construction and modernization a priority. On Aug. 13, 1946, Harry Truman signed the Hill-Burton Act, giving communities grants and loans for hospital construction. By 1975, almost one-third of American hospitals owed their creation to the law. Financing for Hill-Burton health care construction ended in 1997, but one rule from the original bill still applied: These hospitals had to give free or reduced care to people who couldn’t afford services. As rural areas aged and the population shrank because of manufacturing’s decline and the rise of a technology-driven economy centered on urban areas, hospitals struggled to stay in operation.

Under the Affordable Care Act, hospitals started shutting down at worrisome rates because of an increase in financial penalties for noncompliance with A.C.A. mandates, the cost of tighter reporting standards and smaller reimbursements for certain procedures. Since the A.C.A. became law in 2010, over 80 rural hospitals have closed nationwide. Maine alone has lost three hospitals in that time, about 10 percent of its rural total.

If closings continue at this rate, 25 percent of America’s rural hospitals will have disappeared in the decade after Obamacare’s passage. This does not take into account facility deterioration, doctor departures or department closures.

This is a big problem for Maine, which has the highest percentage of rural residents in the country, according to the most recent census data. Calais Regional Hospital in Down East Maine recently oversaw its last childbirth. The obstetrics department closed in late summer, forcing women in labor to drive 50 minutes to deliver their babies. Despite an opioid crisis that increases the chance of high-risk pregnancies, this same privately owned hospital shut down its pediatrics wing and intensive care unit in recent years, because of financial pressure from the management company halfway across the country in Tennessee.

This was hardly an isolated example in Maine. The town of Jackman closed its 24-hour emergency room in September, and Boothbay lost its only hospital in 2013. Rangeley, where my wife’s family lives, is an hour away from the nearest hospital and has no doctor in town.

Meanwhile, Maine Med in Portland, Maine’s largest city, is about to break ground for a $512 million addition just a few years after it finished a $40 million renovation. While rural Maine’s hospitals and departments are closing because of large losses, Maine Med had, for 2016, a $61 million surplus.

Medicaid expansion is a welcome source of new revenue to rural hospitals in Maine because more insured patients mean fewer uncompensated treatments. Still, it comes nowhere close to fixing the problem or, politically, putting any meaningful points on the Democratic scoreboard.

In 2016, Donald Trump won Maine’s rural congressional district by a 10-point margin and rural counties in America at large by a 26-point margin on a message of repealing and replacing Obamacare. As Maggie Elehwany of the National Rural Health Association said in an NPR interview this year, rural Americans voted for Mr. Trump in part because of health care. “They see their hospitals closing,” she noted. “And one hospital C.E.O. described it as a three-pronged stool. It’s the churches, the hospitals and the schools. If you lose one of those legs of that stool, the whole community collapses.”

Since President Trump hasn’t been able to deliver on any meaningful legislation to support rural voters, it is the Democrats’ time to deliver. One good step is a bill sponsored by the Democratic senators Tim Kaine of Virginia and Michael Bennet of Colorado called Medicare-X. It would give a public option to Americans in rural counties where limited competition has yielded higher-priced health insurance options.

It still doesn’t solve the heart of the rural problem. Democrats can’t just lower premiums and expand Medicaid. We must strengthen rural communities by making access to high-quality health care services a priority of any proposal. In any future legislation, we should demand grants for new hospitals, funds to modernize crumbling ones and financial incentives for top doctors to work in these areas. This will not only make rural communities healthier, but also more welcoming for growth and new business.

No person suffering from a heart attack should die because a hospital is too far. No pregnant mother should have to risk the health of her baby because she can’t make it to a delivery room in time. As Democrats, we believe that health care is a right. It would be a big mistake to expand health care insurance but offer no place to use it.

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Effort Launches to Expand Medicaid in Maine Through Ballot Initiative

Mainers for Health Care officially launched their campaign to expand Medicaid though a ballot initiative this November.

Dr. Elizabeth Rothe, a family medicine physician at Central Maine Medical Center, says expanding the insurance program will not only help an estimated 70,000 Mainers, it will also help hospitals.
"Caring for patients who cannot pay their bills puts hospital budgets in the red," Rothe says. "It jeopardizes jobs, departments, and even entire hospitals. Maine needs to expand Medicaid."
Under the Affordable Care Act, states that expand Medicaid receive extra federal dollars. Maine lawmakers have approved expansion five times, but Governor LePage has vetoed the legislation.

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Hospitals tackle uncompensated care costs

ATLANTA – Georgia’s hospitals continue to be a major economic force in spite of growing uncompensated care costs statewide, according to a new report.

An annual report from the Georgia Hospital Association, an advocacy group, concluded that hospitals in the state contributed nearly $47.8 billion to the economy statewide in 2015.

Across the state, facilities collectively had more than 141,000 full-time employees on their payroll and indirectly created more than 344,000 jobs, with hospital purchases supporting medical supply businesses and others.

South Georgia Medical Center in Valdosta had 2,003 full-time employees in 2015, according to hospital spokeswoman Laura Love. More than 4,800 jobs were indirectly created by SGMC, the report says.

The hospital's Valdosta campus provided $23,206,976 in uncompensated care that year, $6.6 million less than in 2012. SGMC's two satellite campuses, in Berrien and Lanier counties, provided uncompensated care valued at $1,166,450 and $1,328,496, respectively, in 2015, according to the report.

In communities such as Moultrie, the hospital represents one of the largest employers. Colquitt Regional Medical Center had 1,114 employees in 2015, with another 2,709 jobs indirectly created.
Yet, Colquitt Regional has also seen its uncompensated care grow to $11.5 million in 2015, which is a 37 percent jump since 2011.

Hospitals across the state provided more than $1.7 billion in services for which they were not paid in 2015.

“Throughout Georgia, hospitals are the only source of medical care for most uninsured residents,” Earl Rogers, the association’s president and CEO, said in a statement.

“Add to that a growing number of residents who actually have insurance but cannot pay their high insurance deductibles, and hospitals end up absorbing even more losses. These dynamics are not sustainable long term,” Rogers added.

A high rate of uninsured Georgians and a Medicaid reimbursement rate that does not cover a hospital’s actual costs have compounded the losses, according to the association.

About 42 percent of all Georgia hospitals reported they operated in the red in 2015, according to the report.

Rural hospitals were hit particularly hard, with 68 percent losing money. Six hospitals have shuttered since 2013, hampering local efforts to attract new industry and leaving residents traveling farther for medical care.

Colquitt Regional is among the minority of rural hospitals that reported a positive margin.

CEO Jim Matney said in an interview this week the hospital spends about $6 million a year on technology to keep the facility’s service offerings current and attractive to the community.

“What causes rural hospitals to close down is not the fact that they’re just rural,” Matney said. “But because they can’t keep up with the services that are being offered.

“For example, if you had to have your gall bladder taken out, would you want it done robotically and have one little stitch or would you rather them go ahead and open you all the way up? That’s a real scenario,” he added.

While South Georgia Medical Center's network as a whole finished in the black in 2015 with a 7.8 percent margin, the Lanier and Berrien campuses lost money, Love said. The Berrien campus lost $403,000, the Lanier campus lost 4165,000, and the Lakeland Villa — a nursing facility alongside the Lanier hospital facility — lost $310,000.

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Hundreds Rally Against Closure Of Topeka Hospital At Center Of Medicaid Expansion Debate

Hundreds of people attended a vigil Monday evening outside St. Francis Health in Topeka, a financially struggling hospital that is at the center of the Medicaid expansion debate in Kansas.

Several hundred people turned out Monday night to protest the possible closure of St. Francis Health in Topeka.

The financial struggles of the 378-bed hospital have taken center stage in the debate over whether to expand KanCare, the state’s privatized Medicaid program.

Republican Gov. Sam Brownback recently vetoed an expansion bill that would have generated an additional $10 million a year in federal funding for St. Francis, according to the Kansas Hospital Association.

The association estimates that the state’s rejection of expansion has cost Kansas health care providers more than $1.8 billion over the past three years.

Carolyn Zimmerman of Topeka was among those at the vigil, where people lit candles, marched to the hospital’s main entrance and sang “Amazing Grace.”

“I hope it will make a difference,” Zimmerman said. “I do think it will demonstrate to the governor that he should be expanding Medicaid.”

St. Francis was established in 1909 by the Sisters of Charity of Leavenworth, an organization now known as SCL Health, based in Denver. Officials from SCL were in Topeka on Monday to meet with members of the St. Francis board, according to Topeka Mayor Larry Wolgast.

Brian Newsome, a spokesperson for SCL, said in an email that he could not confirm the meeting.

“We have no announcement at this time but will keep our dedicated associates and physicians, and the community they serve, informed when we have definitive news to share,” Newsome said.
Brownback sent a news release Tuesday morning stating that Mike Slubowski, CEO of SCL Health, told him SCL wouldn’t make an announcement Tuesday. He said Slubowski committed to “work with us” to keep St. Francis open.

“I intend to hold Mr. Slubowski to his commitment and anticipate further negotiations in the coming days and weeks,” Brownback said. “As I have said previously, St. Francis is an important local and regional health care provider, and a significant Kansas charitable asset that has long served its stated mission of improving the health of those who are poor and vulnerable.”

Dr. Jacqueline Hyland, a St. Francis anesthesiologist, said at Monday’s vigil that the staff is in the dark about SCL’s plans.

“It’s been very quiet,” Hyland said. “But there are lots of rumors out there and fear that the hospital may close.”

Hyland was among many who said she hoped the show of community support would influence SCL’s decision about the hospital’s future.

“I hope that they see how important this hospital is to each individual who is out here showing their support,” she said.

Another employee, Anna Munns, organized the vigil. She has worked in the registration office for the past 17 years.

“I’m a very prayerful person, and I think God has a plan for the hospital,” Munns said. “I’m just hoping and praying that somebody steps in and does something.”

Opponents of Medicaid expansion insist it cannot fix the problems facing St. Francis and other struggling hospitals across the state, including those in Fort Scott and Wellington. But David Heinemann, a former Kansas legislator who attended the vigil, said he believes expansion could help stabilize many of the state’s troubled hospitals.

“I’m very hopeful that the Legislature will reconsider Medicaid expansion,” said Heinemann, a Republican who represented Garden City in the Kansas House from 1968 to 1995 but now lives in Topeka.

“We know in the legislative process that it’s never over until it’s over,” he said.

Earlier this month the House fell three votes short of overriding Brownback’s veto of the expansion bill.

Supporters will attempt to pass a new expansion bill when lawmakers return May 1 to wrap up the 2017 session. House Minority Leader Jim Ward, a Wichita Democrat, is optimistic that supporters will switch enough votes to pass the new bill with a veto-proof majority.

“I do think there’s a good chance of us flipping those votes,” Ward said.

Expansion would qualify all non-disabled Kansas adults earning up to 138 percent of the poverty level, annually about $16,642 for an individual and $33,465 for a family of four, for Medicaid coverage.

Expansion would make an estimated 300,000 additional Kansans eligible for coverage though only about 180,000 would initially enroll, according to estimates.

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N.J. Hospitals Sustained Nearly $1.5 Billion in ACA Funding Cuts

Hospitals and health systems in New Jersey have already absorbed nearly $1.5 billion in funding cuts since the Affordable Care Act was enacted in 2010, with the promise of expanded healthcare coverage to mitigate these losses. As the 115^th Congress advances legislation to repeal major provisions of the ACA, healthcare providers are concerned the cuts will remain despite the coverage of 796,291 state residents being jeopardized.

Individual hospitals have experienced funding cuts as high as $74 million from 2010 to 2017, according to modeling performed by the New Jersey Hospital Association.

Hospitals aren't the only providers affected by these cuts; New Jersey's post-acute facilities have seen more than $430 million cut from their funding, according to NJHA.

NJHA's modeling also showed the cuts yet to come if Congress and the new Administration do not pass an appropriate replacement plan. New Jersey hospitals will see added cuts totaling $1.1 billion through 2019, while post-acute care providers will sustain another $325 million in cuts.

NJHA is calling on lawmakers to pass a simultaneous replacement plan if the ACA is repealed. Barring that, these deep funding cuts should be returned to providers to allow them to care for the people who face the loss of newfound coverage, says NJHA.

"The impact of repeal without replacement – or restoration of these funding cuts – would be devastating to hospitals and other healthcare providers," said Betsy Ryan, president and CEO of NJHA. "So many of the strides we've made in expanding access to healthcare – and in reforming our healthcare system for the future – are now in danger of being walked back."

At stake in New Jersey are issues of access to quality care and financial stability for facilities and the state government, including:

• A total of 796,291 New Jersey residents have been covered under Medicaid and the Health Insurance Marketplace since the ACA's coverage provisions took effect in 2014.
• A stark reduction of insured New Jerseyans would create a dramatic increase in the demand for charity care services. That would be a double blow to hospitals that have seen state charity care funding cut by $350 million in the last two state budgets.
• More residents of New Jersey would access care through the emergency department, which is not effective for patients, increases wait times for all and increases healthcare costs.
• The state could lose federal matching dollars under Medicaid expansion, to the tune of $4.4 billion annually.
• New Jersey residents could lose $795 million in federal subsidies that helped them pay for their insurance premiums.
• Individuals' access to services such as mental health and substance use disorder care and preventative care could be jeopardized.
• Further impacts include reduced investment in population health, quality improvement and health information technology; an unraveling of the healthcare safety net; and deep payment cuts to nursing homes and other post-acute providers that care for the most vulnerable and frail New Jerseyans.
• The additional strain on hospital budgets of caring for more indigent patients would force extremely difficult – and often unpopular – choices about availability of services, staffing and reinvestments and modernization.
• The state could lose 86,400 jobs, according to an analysis by the Commonwealth Fund. These job losses would be felt in the healthcare sector as well as other industries including construction, real estate, retail and insurance.

New Jersey's healthcare sector is the state's second largest employer; hospitals alone provide more than 142,000 jobs and $22.7 billion in total contributions to the economy. Hospitals also provide more than $2 billion in added community benefits – beyond healthcare services – in their local municipalities.

"We have always been grateful to Gov. Chris Christie and his Administration for strengthening the safety net of the state and expanding Medicaid," noted Ryan. "I look forward to working with our state and federal lawmakers to continue to keep the well-being of New Jersey's residents and its healthcare system as a priority."

Additional detail can be found at http://www.njha.com/pressroom/2017-press-releases/jan-26-2017-nj-hospitals-sustained-nearly-15-billion-in-aca-funding-cuts/ . NJHA President and CEO Betsy Ryan will hold a telephone briefing for reporters Jan. 26 at 1:30 p.m. EST. To call in, dial 609-275-4100 or 1-800-342-0505 and ask for the NJHA media briefing.

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Vermont to Launch a First-in-the-Nation All-Payer System for All Healthcare Providers

As recently reported by Modern Healthcare and other major healthcare news outlets, the Obama administration has granted tentative approval for Vermont to establish an all-payer reimbursement system. If granted final approval, the Vermont All Payer Accountable Care Organization Model (Model) would be effective for five years from January 1, 2017 to December 31, 2022. The Model would be the first in the nation to cover all healthcare providers. By way of contrast, Maryland’s well-known all-payer system only covers hospitals.

The Model is based on Medicare accountable care organizations. If approved, all healthcare providers in Vermont would be paid global rates based upon quality and total cost of care expenditures, rather than the traditional fee-for-service payment methodology.  The Model and its quality-based payment methodology would create a path for providers to get to Merit-based Incentive Payments or Alternative Payment Model payments being mandated under the Medicare Access and CHIP Reauthorization Act, known as MACRA.  Finally, the Model would allow Vermont providers to participate in the Medicare Shared Savings Program ACO model, Next Generation ACOs, or full capitation under the prepaid model.

In its development of the Model, the state considered a single-payer model similar to the one proposed by Senator Bernie Sanders. However, the single-payer model was abandoned after estimates found that it would cost Vermont an additional $2 billion in its first year.

Finally, before the Model becomes law, there will be a public process in Vermont. The draft Model agreement as tentatively approved by the Obama administration remains under final legal review by Vermont and CMS.  If the Model survives the final legal review process, the final Model agreement will need to be signed by the Vermont governor and health administrators.

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Letter: Take back health care from corporate interests

Kathy Waller, September 27, 2016

The health care system in the United States is rigged.  We are the richest country in the world — and the only industrialized nation that does not provide universal health care to all citizens. Our health care financing system puts corporate profits ahead of people, working for millionaires but not for us. While patients suffer and die, United’s CEO is paid $66 million a year. Aetna recently abandoned the ACA health insurance exchanges, claiming that they were unprofitable, while posting $7 billion in overall profits last year. One-third of every dollar that we pay for premiums is spent on administrative waste, including exorbitant CEO salaries, shareholder profits, political lobbyists, and marketing campaigns designed to spread fear and lies about health care reform.

Our health care system is in medical, economic and moral crisis. In Colorado, 535 people die each year from causes that would have been avoidable if they could have afforded medical care. We spend nearly twice as much per capita than any other wealthy country, with worse outcomes. Medical debt is the greatest contributor to bankruptcies. There is a perverse incentive for profit-driven insurance companies to deny as much care as they can get away with in order to maximize profits for their shareholders.

It’s time for a Health Care Revolution! Health care should be a right, not a privilege, and the people of Colorado have a chance to lead the nation in saying “no” to the obscene profit-driven motives of insurance companies by joining together as co-owners of a cooperative health care financing system, ColoradoCare, with the motive of providing actual health care to all. ColoradoCare will cover all Coloradans, save billions and provide high-quality care. No more deductibles or narrow networks. This is not government-run health care; there will be transparency and accountability to us as owners of the cooperative, a proven business model. The system will exemplify high-quality medical care, fiscal responsibility and social justice.

It’s time to take back our health care from corporate interests. Learn more at www.coloradocare.org. Stand against the status quo of the robber baron pharmaceutical and insurance industry profiteers. Vote yes for Amendment 69 — ColoradoCare. Join the Health Care Revolution and Feel the Care!

Kathy Waller, M.D., Fort Collins
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A state-by-state breakdown of 77 rural hospital closures

Of the 25 states that have seen at least one rural hospital close since 2010, those with the most closures are located in the South, according to research from the North Carolina Rural Health Research Program.

Ten hospitals in Texas have closed since 2010, the most of any state. Tennessee has seen the second-most closures, with eight hospitals closing since 2010. In third place is Georgia with six closures followed by Alabama, which has seen five hospitals close over the past six years.

Listed below are the 77 rural hospitals that have closed since 2010, as tracked by the NCRHRP. For the purposes of its analysis, the NCRHRP defined a hospital closure as the cessation in the provision of inpatient services. Although all of the facilities listed below no longer provide inpatient care, many of them still offer other services, including outpatient care, imaging, emergency care, urgent care, primary care or skilled nursing and rehabilitation services

Alabama
Chilton Medical Center (Clanton)
Elba (Ala.) General Hospital
Florala (Ala.) Memorial Hospital
Randolph Medical Center (Roanoke)
South West Alabama Medical Center (Thomasville)
Arizona
Cochise Regional Hospital (Douglas)
Florence (Ariz.) Community Healthcare
Hualapai Mountain Medical Center (Kingman)
California
Colusa (Calif.) Regional Medical Center
Corcoran (Calif.) District Hospital
Kingsburg (Calif.) Medical Center
Georgia
Calhoun Memorial Hospital (Arlington)
Charlton Memorial Hospital (Folkston)
Hart County Hospital (Hartwell)
Lower Oconee Community Hospital (Glenwood)
North Georgia Medical Enter (Ellijay)
Stewart-Webster Hospital (Richland)
Illinois
St. Mary's Hospital (Streator)
Kansas
Central Kansas Medical Center (Great Bend)
Mercy Hospital Independence (Kan.)
Kentucky
New Horizons Medical Center (Owenton) 
Nicholas County Hospital (Carlisle)
Parkway Regional Hospital (Fulton)
Westlake Regional Hospital (Columbia)
Maine
Parkview Adventist Medical Center (Brunswick)
Southern Maine Health Care – Sanford Medical Center
St. Andrews Hospital (Boothbay Harbor)
Massachusetts
North Adams (Mass.) Regional Hospital
Michigan
Cheboygan (Mich.) Memorial Hospital
Minnesota
Albany (Minn.) Area Hospital 
Lakeside Medical Center (Pine City)
Mississippi
Kilmichael (Miss.) Hospital
Merit Health Natchez (Miss.) – Community Campus
Patient's Choice Medical Center of Humphreys County (Belzoni)
Pioneer Community Hospital of Newton (Miss.)
Missouri
Parkland Health Center – Weber Road (Farmington) 
Sac-Osage Hospital (Osceola)
SoutheastHEALTH Center of Reynolds County (Ellington)
Nebraska
Tilden (Neb.) Community Hospital
Nevada
Nye Regional Medical Center (Tonopah)
North Carolina
Blowing Rock (N.C.) Hospital
Franklin Regional Medical Center (Louisburg) Vidant Pungo Hospital (Belhaven)Yadkin Valley Community Hospital (Yadkinville)
Ohio
Doctors Hospital of Nelsonville (Ohio)
Physicians Choice Hospital-Fremont (Ohio)
Oklahoma
Epic Medical Center (Eufaula)
Memorial Hospital & Physician Group (Frederick)
Muskogee (Okla.) Community Hospital
Sayre (Okla.) Memorial Hospital
Pennsylvania
Mid-Valley Hospital (Peckville)
Saint Catherine Medical Center Fountain Springs (Ashland)
South Carolina
Bamberg (S.C.) County Memorial Hospital
Marlboro Park Hospital (Bennettsville)
Southern Palmetto Hospital (Barnwell)
Williamsburg Regional Hospital (Kingstree)
South Dakota
Holy Infant Hospital (Hoven)
Tennessee
Gibson General Hospital (Trenton)
Haywood Park Community Hospital (Brownsville)
Humboldt (Tenn.) General Hospital
McNairy Regional Hospital(Selmer)
Parkridge West Hospital (Jasper)
Pioneer Community Hospital of Scott (Oneida)
Starr Regional Medical Center-Etowah (Tenn.)
United Regional Medical Center (Manchester)
Texas
Bowie (Texas) Memorial
East Texas Medical Center-Clarksville
East Texas Medical Center-Gilmer
East Texas Medical Center-Mount Vernon
Good Shepherd Medical Center (Linden)
Hunt Regional Hospital of Commerce (Texas)
Lake Whitney Medical Center (Whitney)
Renaissance Hospital Terrell (Texas)
Shelby Regional Medical Center (Center)
Wise Regional Health System-Bridgeport (Texas)
Virginia
Lee Regional Medical Center (Pennington Gap)
Wisconsin
Franciscan Skemp Medical Center (Arcadia)
More information on the rural hospitals that have closed since 2010 can be accessed here. 

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8 myths about covering the uninsured in Idaho

Sometime this summer, a committee of lawmakers will start to sort out what a wary Legislature might find palatable by way of accepting billions in federal funding to help thousands of Idahoans who have thus far lost out on the promise of better, affordable health care envisioned under the 2010 Affordable Care Act.

Idaho is the only Republican-controlled state that saw the economic advantage in creating its own health exchange. Three years on, Your Health Idaho ranks among the most successful in the nation in terms of enrollment, service delivery and cost control.

But die-hard opposition to Medicaid expansion makes it Idaho’s last unfinished piece of ACA business. The ad hoc panel has yet to schedule its first meeting, but when it convenes this summer, on the agenda will be how, or whether, to subsidize health coverage for a population whose meager incomes land them in a Catch-22, earning too little to apply for subsidized insurance on the state exchange but too much to qualify for standard Medicaid.

The panel will rake over the ashes of the plan that died in the final hour of the 2016 session in March, when the House balked at a Senate bill to move expansion forward. If it had passed, state officials would be working with the feds on a state-managed program to administer the estimated $7.5 billion in additional federal aid Idaho stands to receive in 10 years of expanded Medicaid.

It’s not just a matter of dollars.

“It’s a much broader question,” said Dr. Andrew Baron, chief medical officer for Terry Reilly Health Services<http://www.trhs.org/>;, whose 16 clinics in Ada, Canyon and Owyhee counties cared for 30,000 patients last year, 58 percent of them uninsured and 70 percent below the federal poverty level. The caseload has ticked up by 500 people since April.

“Do we want to disregard those that are poor, or do we feel that we should be helping them, and I believe that we should absolutely be helping them with Medicaid expansion,” Baron said.

Lawmakers already have weighed in on the subject. The Legislature was represented on two governor-appointed work groups that, in 2012 and 2014, each endorsed a custom, Idaho-managed expansion option. Nothing much has changed since, although several more Republican-controlled states have opted for and created their own customized expansion plans. Gov. Butch Otter could negotiate a plan with the federal government <http://www.idahostatesman.com/news/state/idaho/article85855792.html>; but has declined to do so without official legislative buy-in.

The new panel does provide a forum for fence-sitting or opposing lawmakers either to get comfortable with expansion or sharpen their talking points against it. Mostly, though, the group will be covering well-plowed ground.

What follows are Medicaid expansion myths, misunderstandings and misconceptions that might surface in their discussions.

1. We can’t afford it

Whether the U.S. ought to fund entitlements such as Medicaid is a philosophical question, not a financial one. Health care costs have risen more slowly since the ACA went into effect, the slowest in 55 years. The argument that the deficit will choke the nation is often cited by advocates of smaller government or those opposed to entitlements. But health care reform has reined in rising costs, not contributed to them.

In Idaho, advocates argue that the state can’t afford not to expand Medicaid in some fashion. The current system costs more because it is inefficient and because it is entirely state-funded through taxes. Costs of indigent care that providers end up writing off mean rates and premiums go up to offset losses. Lost productivity is greater with a lesser standard of care, with ripples through the economy.

For the fiscal year beginning next July, expansion would represent about a $600 million infusion of new cash into the state economy, creating jobs, spurring investment and sales, and boosting tax revenue, not to mention improving health for tens of thousands of Idahoans and reducing lost productivity. The University of Idaho has calculated the economic impact of that windfall, in terms of increased sales, output and compensation, at more than triple the federal cash — nearly $2 billion, with another $38 million more collected in taxes.

Turning down Medicaid expansion dollars means Idahoans are rejecting funds they have already paid into the health care system via their taxes. Idaho is effectively subsidizing other states that have expanded Medicaid. With expansion, the state’s health care costs for the uninsured would drop by 20 percent the first year, from $57.7 million to $45.4 million, with a better standard of care.

Idaho could have saved nearly $100 million more if it had opted for expansion two years sooner. Over time, the savings flatten out, and in the long run the state outlay will be higher, but with offsetting benefits. Through 2026, the cumulative cost to the state is forecast at $812 million. Maintaining the status quo would cost $594 million, $218 million less. But the gap group would still lack health coverage; the care they do obtain would remain inefficient, its costs borne by the state; and Idaho’s economy would be billions of dollars poorer.

“From a dollars to dollars comparison, yes, there are increased costs,” said Brian Whitlock, president and CEO of the Idaho Hospital Association. “But with that come increased benefits, and that is a reduction in property tax, a reduction in the amount of state general funds that go to the catastrophic health care, and in return you get an infusion of hundreds of millions of dollars back into the economy from the matched Medicaid dollars.”

2. Medicaid is broken and Idaho shouldn’t expand it

If you oppose entitlement programs in general, then you won’t be swayed by the argument that Idaho’s Medicaid premiums have grown slower than commercial rates — 5 to 10 percent slower since 2011. Its program is one of the leanest in the nation. Its expansion plan would be unique, and different from standard expansion. The state would seek permission from the federal government for options that could include copays and other requirements for participants.

Since 2014, the state quietly has been reinventing how Idaho delivers health care. With the help of a $40 million, four-year federal grant<http://ship.idaho.gov/>;, it is moving away from the traditional fee-for-service model that drives higher costs, and toward a better-coordinated, holistic approach that delivers better care at lower cost.

3. The gap population is made up of able-bodied adults who should be working

They are working. Two-thirds of gap households have earned income. They work in food service, construction, agriculture, home health care, child care, retail sales, transportation, office and admin support, and in janitorial services. About 12 percent have income from social security, child support or a pension.

Even with jobs they still make less than 100 percent of the federal poverty level and are not eligible to buy subsidized insurance on the state’s health exchange. And they earn too much to be eligible for traditional Medicaid. Some other statistics:

55 percent are female.

84 percent are 18-50 years old.

65 percent of gap households have at least one child at home. The child is on Medicaid, the parents are in the gap.

25 percent are single-person households; 17 percent are two people; 58 percent have three or more.

4. Where did this 78,000 figure come from anyway?

Milliman, an actuarial firm working for the state, arrived at that number based on census and demographic data. A January 2016 update to its original findings puts the gap population at 78,581. Separately, the Department of Health of Welfare last year looked at Idahoans currently receiving public assistance in some form and identified 51,808 people who would receive benefits under expansion. Whatever the actual difference, it represents a population that currently receives no other benefits or assistance.

5. It’s not an issue where I live

Based on the IDHW headcount cited above, there are people in the gap in every county in the state. Their numbers are highest in southwest and eastern Idaho and range statewide from under 1 percent to 4.6 percent of county population. The counties with the highest rates are Bannock, Canyon and Shoshone. The largest gap populations are found in Ada, Canyon and Kootenai.

6. The gap population has access to health care already

The care they receive is minimal — until an expensive emergency occurs. The state’s community health centers report that low-income people seek care only when they are really sick or injured. There is no provision for preventive care or a long-term treatment, no management of chronic conditions, no coordination to guide follow-up care.

People in poverty suffer a higher prevalence of chronic diseases, a sign of substandard or delayed medical care. They are twice as likely to suffer from depression; half again as likely to have asthma, diabetes or suffer a heart attack; 25 percent more likely to be obese; and 10 percent more likely to have high blood pressure.

In describing their plight, Yvonne Ketchum-Ward, CEO of the Idaho Primary Care Association, tells people to put themselves in the position of someone who’s uninsured, struggling to cover rent and the food budget, “and then they start not to feel well.”

They might know they can go to a clinic for primary care of a specific condition at sliding-scale cost, she said, but they put off treatment when the cause of their ailment is unknown, and with it, the cost to treat it.

What’s more, there’s a limit to what a clinic can treat.

“If you do find out that you’ve torn your meniscus in your knee and you need surgery to fix it, that can’t be done in one of our clinics,” Ketchum-Ward said. “And if you don’t have the money to pay for it, you usually don’t have the money to manage the pain, and it causes you not to function as well. Maybe you can’t work as well. It’s a vicious cycle.”

7. These are long-term welfare recipients

IDHW looked at six years of data on enrollments for food stamps, now known as SNAP, from the peak of the Great Recession to present. Of 575,000 enrollees in that period:

75 percent, or 431,000, cycled on and off assistance one or two times due to a temporary crisis, most commonly a job loss.

16 percent, or 92,000, cycled on and off three or more times. Typically, these were people with seasonal or fluctuating incomes who were right at the margin for income eligibility.

5 percent, or 28,750, were on assistance for an extended period. Typically, these were people in their 50s who lost employment.

4 percent, or 23,000, received assistance continuously for all six years. Of those, almost half were disabled or had a disabled person in the household; 32 percent were single moms with children; 27 percent were seniors; and 37 percent were two-parent households with kids. Of the last group, 92 percent had earned income.

For the entire population, the average length of time on food stamps was 13 months.

8. Idaho doesn’t have enough doctors to handle it

Susie Pouliot, CEO of the Idaho Medical Association, often hears this.

“What I typically say is, even if we didn’t have enough doctors, is that a reason to deny health care?” she said. “No, it’s not.”

Pouliot noted efforts to broaden the pipeline, from new and expanded training programs to loan repayment and recruiting incentives to attract more physicians. The federally-funded SHIP program, in which health care professionals work in teams to address the range of patient’s needs, “can take better care of patients and take care of more patients than just a physician working in a traditional model,” she said.

“Yes there will be an initial surge of people seeking access because they have had unmet health care needs for a long time,” she said. “But that evens out over time.”

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In surprising turnabout, Oklahoma eyes Medicaid expansion

"We are nearing a colossal collapse of our healthcare system in Oklahoma," warned Craig Jones, the president of the Oklahoma Hospital Association."

 

By Associated Press  | May 16, 2016 - Despite bitter resistance in Oklahoma for years to President Barack Obama's healthcare overhaul, Republican leaders in this conservative state are now confronting something that alarms them even more: a huge $1.3 billion hole in the budget that threatens to do widespread damage to the state's healthcare system.

So, in what would be the grandest about-face among rightward leaning states, Oklahoma is now moving toward a plan to expand its Medicaid program to bring in billions of federal dollars from President Obama's new healthcare system.

What's more, GOP leaders are considering a tax hike to cover the state's share of the costs.

"We're to the point where the provider rates are going to be cut so much that providers won't be able to survive, particularly the nursing homes," said Republican state Rep. Doug Cox, referring to possible cuts in state funds for indigent care that could cause some hospitals and nursing homes to close.

Despite furious opposition by conservative groups, Republican Gov. Mary Fallin and some GOP legislative leaders are pushing the plan, and support appears to be growing in the overwhelmingly Republican Legislature. Details have not been ironed out but the proposal is based on an Indiana program that received federal approval.

President Obama called on states to expand their Medicaid insurance for low-income residents as part of his 2014 health overhaul designed to shrink the population of uninsured Americans. Most Democratic-led states did so, along with a handful of GOP states.

But in Oklahoma, even with 20 percent of its population on Medicaid, it's been no way, no how. Until now.

A bust in the oil patch has decimated state revenues, compounded by years of income tax cuts and growing corporate subsidies intended to make the state more business-friendly.

Oklahoma's Medicaid agency has warned doctors and other healthcare providers of cuts of up to 25 percent in what the state pays under Medicaid.

"We are nearing a colossal collapse of our healthcare system in Oklahoma," warned Craig Jones, the president of the Oklahoma Hospital Association, which represents more than 135 hospitals and healthcare systems in the state. "We have doctors turning away patients. We have people with mental illnesses who are going without treatment. Hospitals are closing, and this is only going to get worse this summer if the Legislature does not act immediately to turn this around."

In the poverty-wracked southeastern corner of the state, where 96 percent of babies in the McCurtain Memorial Hospital are born to Medicaid patients, most healthcare would end, said hospital CEO Jahni Tapley.

"A 25 percent cut to Medicaid would not put my hospital in jeopardy, because we are already in jeopardy," Tapley said. "A 25 percent cut would shutter our doors for good, leaving 33,000 people without access to healthcare."

Nursing homes have been warning residents that they may be closing. Asked where she would go if the Beadles Nursing Home in the small town of Alva closes, Jeanie Yohn, 89, said: "I just can't imagine. I have three daughters, but they don't live here."

Under the proposal, which would be funded in part with a $1.50-per-pack tax on cigarettes, Oklahoma would shift 175,000 people from its Medicaid rolls onto the federal health exchange created by the Affordable Care Act. That would make room for adding to Medicaid roughly the same number of working poor who are currently uninsured. Participants would pay nominal premiums and co-pays.

The move, by increasing the number of uninsured people covered, would allow the state to tap into the extra money offered under the federal law. Beginning in 2017, the federal government would cover 95 percent of the state's Medicaid costs, decreasing to 90 percent of the share in 2020.

Fallin, a former congresswoman who voted against Obama's health plan when it came before the House, argues that the plan doesn't amount to expanding Medicaid because the program's rolls don't grow. Rather, she said, it "transitions 175,000 Medicaid enrollees to the private insurance market."

No matter what state leaders call it, conservative groups aren't happy about the idea of more government health spending.

"They can call it Medicaid rebalancing, but there's only one federal program that offers a 9-to-1 federal match, and that's Obamacare," said Johnathan Small, president of Oklahoma Council on Public Affairs, a free-market think-tank that opposes higher taxes. The opponents have called for covering health costs by cutting spending for less essential programs.

Americans for Prosperity, another conservative think-tank backed by the billionaire philanthropist Koch brothers, David and Charles, also has launched a campaign against the proposal and is hosting a "NobamaCare" event at the state Capitol to voice their opposition.

 

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More Red States Embrace Obamacare, As Long As You Don’t Call It That

Republicans are tying themselves in knots over health care for the poor.

Presidential candidates and other national politicians throw around a lot of rhetoric about health care reform, but the real action is happening in conservative state legislatures across the country.

Red state governors and lawmakers are deciding what health care for low-income people and those with disabilities delivered through Medicaid, the joint federal-state health benefit program, will look like in the post-Obamacare era. 

“This, at this point, is largely a fight within the Republican Party,” said Joan Alker, executive director for the Center for Children and Families at Georgetown University, who is an expert on Medicaid issues.

In some cases, Republicans have concocted pretty convoluted ways to do Obamacare without saying they’re doing Obamacare, to get other Republicans to go along.

The passage of the Affordable Care Act in 2010 and a Supreme Court decision two years later affirming states’ rights to refuse to participate in the law’s Medicaid expansion triggered this fight. 

The ACA called for Medicaid to be available to anyone earning up to 133 percent of the federal poverty level, or $16,000 for a single person, and provided full federal funding from 2014 through 2016, after which Washington gradually contributes less until 2021 and future years, when states will pay 10 percent of the costs. The federal government pays an average of 57 percent of other Medicaid expenses.

Thirty-one states and the District of Columbia have expanded Medicaid, which has been a key contributor to the historic reduction in the uninsured rate since 2013.

Democratic states quickly took up this arrangement, which enabled them to advance the cause of covering the uninsured at little cost to their budgets. So did states with divided government, including Kentucky and New Jersey, and even some GOP-led states like Nevada and North Dakota. 

Republican interest in participating in Medicaid expansion grew after Arkansas’ divided government won federal approval for a privatized model. After that, states with Republican leadership, such as Michigan and Ohio, joined in. 

This year, expansions, contractions, cuts and sweeping reforms are on the docket in states like Alabama, Oklahoma and South Dakota.

In those places and elsewhere, ideology about the role of government and about the Affordable Care Act itself is running into practical realities about access to health care and the availability of federal dollars.

South Dakota: A ‘Win-Win-Win’

When the opportunity first presented itself in 2012, South Dakota Gov. Dennis Daugaard (R) rejected Medicaid expansion, portraying it as a handout to “able-bodied” people who didn’t want to work.
Even when he changed his tune last year and found a way to support expansion, Daugaard expressed “hate” at the idea of making people dependent on the government.

But what Daugaard saw is that taking federal money to expand Medicaid and cover more uninsured in South Dakota also would allow the state to reduce spending on other programs, and to address longstanding problems with access and quality of health care for American Indians in the state who use the federal Indian Health Service. 

Federal authorities have cleared the plan, and the state government already is preparing to carry it out. 

“It is a unique opportunity, and it really does appear to be a win-win-win,” said Carole South-Winter, a professor who studies health policy at the University of South Dakota in Vermillion.

The South Dakota legislature ended its session without considering the expansion, but the state’s top health official says Daugaard may call them back for a special session. 

Despite conservative opposition to Obamacare, legislators are open to the proposal, which Daugaard promises will cost the state nothing, South-Winter said. “If it works, it’s genius.”

Oklahoma: Expansion By Contraction

Anyone who needs a reminder of the wacky politics of Obamacare need only consider this: In order to sell a proposed Medicaid expansion in the Sooner State, the administration of Gov. Mary Fallin (R) is framing it as a contraction of the program. 

“The governor and others have gone from being total refuseniks on the Affordable Care Act to saying, ‘Yeah, just don’t call it that,’” said David Blatt, executive director of the Tulsa-based Oklahoma Policy Institute. “This is a really, really high-stakes gamble.”

Here’s how that works: The Oklahoma Health Care Authority wants legislative approval for a plan that would move some pregnant women and children currently on Medicaid onto the federally subsidized health insurance exchanges created by the Affordable Care Act. 

At the same time, they would open up Medicaid to more poor adults through the state’s Insure Oklahoma program. The proposal also would create new financial requirements for Medicaid beneficiaries. The net result would be fewer Oklahomans on Medicaid, and less spending by the state government.

Oklahoma Health Care Authority

A slide from the Oklahoma Health Care Authority’s Medicaid 

reform proposal, which shows the program shrinking even as

more people gain health coverage overall.

Oklahoma is one of several states facing budget shortfalls this year because of low oil prices.
Since Medicaid is one of the largest items in the budget, it’s a target for cuts. But simply slashing payments to medical providers would be difficult. The state proposed cutting fees by a quarter, which the health care industry contends would force hospitals and nursing homes out of business and drive doctors to stop treating Medicaid patients.

Another solution is the Medicaid expansion and reform, and Republican lawmakers have warmed up to it, Blatt said.

The main obstacle at this point isn’t the Obamacare question, Blatt said, but disagreement among legislators about another component of the plan: a $100 million increase in taxes on tobacco products.

Arkansas: Trickery Preserves Expansion

Gov. Asa Hutchinson (R) kept his views of the state’s privatized Medicaid expansion to himself while running for office in 2014. The so-called private option, which uses Medicaid funds to pay for private insurance, was the creation of Hutchinson’s Democratic predecessor, Mike Beebe, and the GOP-led legislature in 2013.

But there are enough staunchly anti-Obamacare lawmakers in that body that the fight must be refought every year, and it’s especially tough because the legislature’s rules require a 75 percent majority to pass spending bills. 

Despite his earlier recalcitrance, Hutchinson stepped up to protect and reform the private option — which he rebranded as Arkansas Works — this year, teaming with Republican and Democratic legislators to keep the program going.

AP Photo/Gareth Patterson

Arkansas Gov. Asa Hutchinson (R) speaks during a town hall in 

Conway in favor of keeping the state's hybrid Medicaid

expansion in place.

Most remarkable, however, was how the final bill became law. In order to overcome the rump group of conservatives defying the majority, Hutchinson came up with an unorthodox plan.

Republicans opposed to the expansion were permitted to add a provision that would repeal it to a big, must-pass budget bill. Supporters of Medicaid expansion had to vote in favor of the legislation, including the repeal language. 

Then Hutchinson used his line-item veto authority to remove that one part of the bill and keep expansion in place, while enacting the rest of the budget.

Democratic legislators were so nervous, one worried what would happen if Hutchinson died before putting pen to paper. And the plan hinged on Republican opponents being satisfied by passing repeal knowing it would never happen. 

Somehow, this worked. And they’ll probably have to do it all over again next year. 

Ohio: Big Changes Need Obama’s OK

Gov. John Kasich (R) has gotten a lot of flack from conservatives for circumventing state legislature to expand Medicaid in 2013, and this supposedly pro-Obamacare move dogged him during his failed pursuit of the Republican presidential nomination. 

This year, Kasich signed legislation favored by Ohio conservatives that would make some significant changes to how the state runs Medicaid. 

Modeled in part on the Healthy Indiana Plan and Medicaid expansion that won federal approval last year, the Healthy Ohio Program would require beneficiaries to enroll in private insurance, pay a portion of their incomes for the benefits and more money for medical care than under traditional Medicaid. That would include people with incomes below poverty level. Elderly Ohioans, people with disabilities, and other more vulnerable beneficiaries would be exempt.

Creating new financial obligations for Medicaid enrollees would result in fewer people with health coverage, say critics, including U.S. Sen. Sherrod Brown (D-Ohio). 

And the plan also would take away coverage from a slew of low-income groups, including breast and cervical cancer patients, and children when they turn 18. The law also would end the normal Medicaid practice of “retroactive eligibility,” which allows the program to pay for recent medical bills for people deemed to qualify for the program.

“The process that’s envisioned under this waiver would result in tens of thousands of people losing coverage,” said John Corlett, president of the Center for Community Solutions in Cleveland, who ran Ohio’s Medicaid program when Democrat Ted Strickland was governor.

The strictest parts of the plan face tough hurdles at the federal level, however. 

No state has ever been allowed to charge money for Medicaid to people who make less than poverty wages, and Health and Human Services Secretary Sylvia Burwell in the past has expressed skepticism about ending retroactive eligibility. 

Alabama: Expansion Hopes Dashed

A task force hand-picked by Gov. Robert Bentley (R) recommended Alabama expand Medicaid last year, and Bentley himself even expressed a new openness to the idea at the time. 

And that’s as far as Alabama came to extending coverage to its poorest uninsured residents. What’s more, budget problems might force cutbacks for current Medicaid enrollees this year.

“He’s facing a legislature that’s controlled by these very, very small-government, more libertarian-minded folks that aren’t going to agree to anything,” said David Becker, a health policy professor at the University of Alabama at Birmingham.

Medicaid expansion has broken through in other conservative states because a governor or group of legislators fought hard for it, and because of pressure from health care interests. That’s not happening in Alabama, Becker said.

“A weak governor who’s kind of wishy-washy on his level of support for doing this hasn’t been helpful. And on the Democratic side, there’s just nothing there,” Becker said.

 

Reuters/Marvin Gentry

Alabama Gov. Robert Bentley (R) needs more money to keep 

Medicaid afloat, but he’s also mired in a sex scandal.

Instead of expansion, Alabama instead is trying to close an $85 million hole in its budget after it requested $100 million from the legislature and got just $15 million. A last-ditch attempt to divert a portion of the state’s settlement with BP over the 2010 Gulf of Mexico oil spill to Medicaid failed, and the legislative session is nearly over.

Without more money from resistant lawmakers, Bentley says Medicaid will have to cut services, including prescription drug coverage for adults, and reduce what it pays medical providers, even as the state continues implementing a prior round of reforms to the program. 

Meanwhile, some legislators want to impeach Bentley over a sex scandal that came to light this year.

Elsewhere

There’s been plenty of action on Medicaid in other states, too.
Louisiana expanded Medicaid under new Democratic Gov. John Bel Edwards. New Hampshire extended its Medicaid expansion after heated debate. Iowa implemented a controversial privatization plan. Kentucky Gov. Matt Bevin (R) wants to apply a version of Indiana’s landmark reforms to his state’s expanded Medicaid program. New Mexico is eyeing payment cuts for doctors and hospitals. And West Virginia may not be able to pay medical providers on time due to budget problem

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