USP Notes: Medicaid expansion edition

Some solid coverage helps keep the debate within the realm of facts

As governors around the country deliver their annual addresses and legislatures prepare to convene, one of the key policy stories of 2013 is cropping up in state after state—whether to accept federal funds promised by the Affordable Care Act and expand Medicaid coverage.

This sounds like eye-glazing stuff, but it’s fairly straightforward: Costs for Medicaid, which covers certain low-income Americans, are shared between state and federal governments. Obamacare widens access to healthcare coverage in part by raising the income threshold for Medicaid, thus expanding eligibility. And under the law the cost of insuring these newly eligible patients is almost entirely borne by the federal government—the feds will pick up 100 percent of the costs for three years after 2014, with the share sliding down to 90 percent in 2022 and beyond.

It’s designed to be an offer that states can’t refuse. But thanks to the Supreme Court’s ruling on the ACA they are empowered to do so, and with hostility to healthcare reform still running high among Republicans, the future course of Medicaid in states with GOP leadership (as well as some run by Democrats) is very much in doubt. Fortunately, some solid reporting from around the country in recent weeks has kept readers up to speed on key developments—and also helped ensure that the public debate is rooted in credible numbers. Here’s a roundup:

— The most surprising development on this front came earlier this week, when Arizona Gov. Jan Brewer—whose movement conservative bona fides are well-established—endorsed a Medicaid expansion in her state. GOP opposition is often tied to arguments that states will end up bearing a higher share of the costs than the ACA promises. But as The Huffington Post’s Jeffrey Young and John Celock write, Brewer hit on an approach that reflects that concern while still accepting federal dollars to expand healthcare coverage:

“As I weighed this decision, I was troubled that a future president and Congress would reduce matching rates,” Brewer said. “Together with my team, I have crafted a plan that addresses both of those concerns and safeguards Arizona.”

Brewer’s plan includes what she described as a “circuit breaker,” which would automatically shrink the state’s Medicaid program in the event that the federal government were to decrease funding.

“I will not allow Obamacare to become a bait and switch,” she said.

Of course, Brewer can’t act by fiat. The state legislature will need to sign on to the expansion, and Mary K. Reinhart of The Arizona Republic has a good write-up of the mixed response to Brewer’s announcement from Arizona’s Republican lawmakers here. Reinhart’s article also has some interesting backstory on how Brewer came to support Medicaid expansion:

Brewer had previously joined 25 states to push for repeal of the federal health-care overhaul and rejected a state-run health exchange, an online insurance marketplace and another pillar of President Barack Obama’s health-care law.

But she was lobbied hard in recent weeks to support Medicaid expansion by a coalition of hospital CEOs and business leaders, represented by former Brewer adviser and state budget director Peter Burns.

Burns and the Arizona Health Care Coalition last month presented a detailed proposal for Medicaid expansion, complete with the number of uninsured patients for each legislative district.

Brewer’s plan, and her reasoning, is similar to that plan: The health-care system is an important economic driver; voters already approved Medicaid expansion in 2000; AHCCCS is a national model; and hospitals are being “pushed to the brink” by costs for the uninsured.

Hmm. Maybe those Tea Party Republicans aren’t so immune to persuasion by big business after all.

— Brewer’s announcement was surprising not just because many state-level Republicans have opposed Medicaid expansion, but because they have often used questionable estimates of the cost to their states to justify that opposition. Of course, we only know that those estimates are questionable because of some solid local reporting.

In Florida last week, for example, Carol Gentry, editor of the site Health News Florida, got ahold of emails showing that costs cited Gov. Rick Scott had been refuted by the state’s chief economist—and that Scott was aware of the pushback but had continued using the inflated numbers anyway. The higher estimates had been produced by a Scott advisor who apparently assumed that the federal government simply would not provide the boost in funding promised under the ACA.

The Tampa Bay Times’s PolitiFact Florida quickly jumped in to declare Scott’s number’s “False,” and the story soon became statewide news, with papers like the Sun-Sentinel editorializing on Scott’s “fuzzy math.” Within days of Gentry’s report, Scott’s office had released a far lower estimate of state costs that reflects the federal contribution; Aaron Deslatte of the Orlando Sentinel has a comprehensive write-up here. Florida may yet reject the Medicaid expansion, but there’s now a better chance that the upcoming debate in the state legislature will be grounded in fact.

— A similar debate is playing out in Ohio, and while it doesn’t share the sexy (well, sexy for wonk news) smoking-gun angle of disregarded emails, The Plain Dealer of Cleveland has been keeping track of it. With Gov. John Kasich preparing his own announcement on Medicaid, the PD’s Sarah Jane Tribble took a thorough look at a think tank report released Tuesday that projected a program expansion would actually produce a net gain for Ohio’s state budget over the next nine years. (The article was prominently featured on Wednesday morning, which was nice to see.)

That study was big news in part because the Kasich administration had previously produced hair-raising estimates of Ohio’s Medicaid costs in coming years. Those forecasts centered around a different population—people who are eligible for Medicaid but not yet enrolled—for whom the federal government will pick up a lower share of the cost. There are likely to be real costs for Ohio there once the ACA’s individual mandate prompts some of those people to sign up for Medicaid, and unlike any expenses associated with expanded eligibility, they aren’t optional for the state. But as an excellent article by The Plain Dealer’s Kate Irby noted last October, Ohio’s projections for those expenses are far above those of neighboring states. That matters because high projected costs to the state for either set of Medicaid patients, whether well-founded for not, offer a reason not to expand the program—or, for that matter, to commit state resources to other projects.

Kasich and his team have been measured in their recent comments, and it’s not clear which way the debate will go. Whatever happens, The Plain Dealer has laid a solid foundation for future coverage.

— The expansion of Medicaid in Georgia is not an especially interesting question—the state looks like a firm no, and The Atlanta Journal-Constitution has been focusing with good reason on a separate, high-profile debate over how to fund the state’s existing program.

Still, a recent item by The New Republic’s Jonathan Cohn that focused on one state lawmaker’s views about Medicaid expansion is a model for writing about how misinformation clouds public discussion of the issue.

Cohn, a liberal who favors expanded healthcare coverage, listened to Sharon Cooper, a Republican state legislator from the Atlanta suburbs, make her case against the expansion—and then he checked out what she said:

But one of her arguments caught my attention, because in more than a decade of covering health policy I’d never heard it before.

The claim was that people on Medicaid sue their doctors more than people who have private insurance. To check its veracity, I consulted Sara Rosenbaum, a professor at George Washington University and expert on Medicaid. “The opposite is true,” she told me, because poor people have less access to lawyers. If anything, she said, people on Medicaid are less likely to sue. The most comprehensive assessment available, from the U.S. Office of Technology Assessment, backs this up. And while that report dates back to 1992, I could find no more recent analysis. (Nor could I get substantiation from Cooper, despite several requests for comment.)

That’s followed by some more health-geek wonkery on other Cooper assertions, and then Cohn’s closing point:

But listening to [Cooper] was a reminder that the fight over health care didn’t end on Election Day, any more than it ended the day Obama signed the Affordable Care Act. The difference? More and more, the debate is taking place away from the national spotlight, in states where dubious claims rarely get the scrutiny they deserve—and in which the political environment is more hostile.

Even if you don’t share Cohn’s policy preferences, it’s a good point—and so as the healthcare debate continues it’s up to journalists from the left, the right, and the traditional media to bring scrutiny to bear on those claims, whatever the local political environment might be.

Follow this writer on Twitter @gregamarx. For more content like this, follow @USProjectCJR.

Related posts:

Eureka! The media discovers Medicaid

Climbing the Medicaid mountain

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Greg Marx is an associate editor at CJR. Follow him on Twitter @gregamarx. Tags: , ,