Medicaid expansion

Alabama Governor Robert Bentley, who "campaigned as an opponent of expanding Medicaid under the Affordable Care Act," now supports expanding Medicaid block-grant funding to more low-income Alabamans, Media Group's Mike Cason reports: Bentley said "he would support an Alabama-designed plan that required recipients to be working or in a work training program. ... Bentley [also] said with a block grant the state could request proposals from private insurers to provide the expanded coverage."

Bentley also suggested that President Barack Obama's administration might be more receptive to his version of a Medicaid expansion because the U.S. Supreme Court has taken up a case posing an existential threat to Obamacare: can the federal government provide tax credits and subsidies to low-income and moderate-income consumers shopping for insurance on the federally-run insurance exchange, instead of state-run exchanges?

Tennessee Gov. Bill Haslam has proposed expanding Medicaid to cover more poor residents of his state, although the plan, if accepted by regulators and conservative legislators, would not follow traditional Medicaid rules, The New York Times' Abby Goodnough reported. Haslam said he still opposes the Obamacare plan to expand Medicaid to everyone earning up to 138 percent of the federal poverty level, but he is proposing a second option to use "federal Medicaid funds available under the law to cover some 200,000 low-income residents through their employer’s health insurance plan or the state’s Medicaid program," Goodnough reported.

Hospitals have found that the amount they spend on charity care or uncompensated care has risen in states that don't have the Medicaid expansion, but fallen in states that do have the expansion.

There is an interesting twist in Haslam's plan that would keep the expansion revenue-neutral for Tennessee, Goodnough reports: Tennessee Hospital Association has agreed to pay expansion costs beyond what the federal government covers. 

Virginia Governor Terry McAuliffe's efforts to expand Medicaid under the Affordable Care Act was thwarted because former Senator Phillip P. Puckett quit the state Senate, The Washington Post's Laura Vozzella reports. McAuliffe had hoped to sneak budget language past the Republicans to expand Medicaid on his own: "Then McAuliffe’s camp found an obscure bit of language in the previous year’s budget that appropriated extra Medicaid funds if — and only if — a newly formed (and hopelessly deadlocked) state Medicaid commission agreed to expansion. If the language was ripped out of that context, the thinking went, McAuliffe could claim that it authorized him to spend an extra $2 billion a year in federal Medicaid funds."

Puckett was enticed to quit by Republicans who discussed jobs for himself and his daughter, Vozzella reports. The jobs nor the Medicaid expansion have come to fruition.

Montana Governor Steve Bullock, a Democrat, has asked legislators once again to expand health coverage for 70,000 low-income Montanans, the Independent Record reports: "Legislative Republicans rejected a Medicaid-expansion proposal in 2013, arguing the state couldn’t afford it and that they didn’t want to implement part of 'Obamacare,' the 2010 federal health-care law. Bullock ... said his new plan is a unique proposal for expanding Medicaid. It would use federal money to contract with a private administrator to process claims and run a network of physicians, hospitals and other providers to serve the newly covered population, he said."

Jason Millman, writing in the Washington Post's Wonkblog, says that the Republican victory in several gubernatorial races means that Medicaid expansion under Obamacare may not happen in several states: "Fifteen of the 23 states that hadn't yet expanded Medicaid held gubernatorial elections last night, and it looks like only Alaska will elect a candidate who campaigned for the Medicaid expansion." There might even be a real chance of undoing Medicaid expansion in Arkansas.

But Millman also notes that several Republican governors have said they might explore expanding their Medicaid coverage and "Medicaid expansion has support from hospitals, which hold considerable political clout and have a lot to lose without the infusion of federal funds from the expansion."

The Washington Post reports that the millions of of enrollees who have benefited from the expansion of Medicaid appear to be "generally happy to have coverage, though many are encountering roadblocks to receiving the care they want, according to new research that provides one of the earliest insights into people's experiences under the expanded health insurance program for low-income Americans." The biggest problem for enrollees has been finding a primary care doctor, the Post further reports, because many doctors won't take new Medicaid patients.

In a separate report, the Los Angeles Times reports that as many as 500,000 people, or 10 percent, who have signed up for coverage under the Affordable Care Act may lose coverage or need to pay more because they haven't verified their citizenship or immigration status, or sent in the forms proving their income. The downside? "The Obama administration may face a backlash from consumers who will be asked to repay hundreds or thousands of dollars in subsidies that they weren't entitled to receive," the Times further reports.

Virginia Gov. Terry McAuliffe is cutting back on his efforts to expand Medicaid healthcare coverage for poor Virginians in the face of strong opposition from Republican legislators, the New York Times reports. The governor has called it '''unconscionable' that such a wealthy state could not provide health care for its needy." The state constitution forbids spending without legislative approval, leading the governor to issue modest orders Monday to cover 20,000 people with severe mental illness and 5,000 kids of low-income state workers.

In huge healthcare news, Pennsylvania Governor Tom Corbett has relented on expanding Medicaid to cover more poor Pennsylvanians under Medicaid, the Huffington Post reports: "Federal regulators accepted a modified proposal from Gov. Tom Corbett (R) that will offer an estimated 500,000 low-income individuals subsidies to purchase private insurance. The plan allows some low-income individuals to be charged premiums for coverage, and permits the number of available benefit plans to be reduced from 14 to two -- a 'high-risk' option and 'low-risk' options -- according to the Pittsburgh Post-Gazette." This makes Pennsylvania the ninth state run by a Republican governor to accept the Medicaid expansion.

The Centers for Medicare and Medicaid Services has clarified that most of the rules of when liens are asserted by the government to recover the money spent on Medicaid health care for long-term care will apply to people who are getting Medicaid under the Affordable Care Act expansion, The Southern reports. States are entitled to asset recovery for all health care benefits, but CMS hopes that states will only impose liens and try to recover from estates for nursing home cases, The Southern also reports.

Separately, NJ.com reports that the "Affordable Care Act encourages states to expand their Medicaid rolls so single people and childless couples can now qualify if poor enough. That means thousands of newcomers to Medicaid may not realize that ultimately they may have to repay the piper."

Many more people are eligible for Medicaid under the Obamacare expansion: adults with incomes under 133 percent of the poverty level. Can the government recover the expenses paid out for these new Medicaid enrollees through liens on their properties and recoveries from their estates?

The Health Affairs blog reports on how the Centers on Medicare and Medicaid Services is advising states on applying liens to consumers who are getting Medicaid under the new expansion. Elderly Americans often get their long-term care paid through Medicaid, but there has been a concern that people "would voluntarily impoverish themselves, transferring assets to their children or to others to make themselves eligible for Medicaid," the blog reports. Medicaid can impose liens on people's houses and other assets to get that long-term care paid back. Now the questions is how the rules about liens should be applied to people who are newly eligible for Medicaid under the Obamacare expansion.

The first upshot, the blog reports, is that liens can't be placed on the property of new Medicaid enrolees. The second upshot is that CMS advises states to try to recover from the estates of new Medicaid receipients who receive long-term care, but not other types of care: "In sum, most of the rules that apply to traditional Medicaid recipients with respect to [long-term care services and supplies] LTSS (except for lien requirements) are likely to apply to [modified-adjusted gross income] MAGI-eligible individuals who receive LTSS.  CMS intends, however, to take steps to avoid applying estate-recovery rules to [modified-adjusted gross income] MAGI-eligible individuals who do not receive LTSS to keep this from becoming a barrier to Medicaid expansion eligibility."