I explored this dilemma with health justice advocates in Virginia, the first state to confront work requirements that had not previously expanded Medicaid. In November 2017, Virginia voters elected a respected new Democratic governor named Ralph Northam along with an eye-popping jump in the number of Democrats in the state’s House of Delegates, leaving them just 2 votes shy of majorities in the House and Senate. In May 2018, solid bipartisan majorities formed to enact Medicaid expansion after years of discouraging defeats. The wrinkle was including a work requirement and imposing cost sharing on Medicaid beneficiaries. Continue reading “The Health Reformers’ Dilemma”
Ever since the U.S. Supreme Court ruled in 2012 that states must have an option whether or not to expand Medicaid as authorized in the Affordable Care Act, expansion has been a long, slow slog, state by state, inch by inch. While blue states had mostly lined up to expand Medicaid by 2013, nearly every purple and red state proved to be a battlefield. Today, 19 states have yet to expand, with 31 in the “yes” column (plus the District of Columbia) (see table 1). The last state to expand, #31, was Louisiana in mid-2016. But, might a mighty Medicaid wave be coming courtesy of the November 6th elections? The answer is a definite maybe.
Right now, all that’s certain is that Virginia will become state #32 to expand Medicaid in January. The state enacted the 400,000-person expansion last May, albeit with a “work requirement” to be filed with the Centers for Medicare and Medicaid Services (CMS) sometime in 2019.
Maine is certain to become #33 early next year if Democratic Attorney General Janet Mills wins the Governor’s Chair. In November 2017, Maine voters approved expansion—59-41 percent—in a state ballot initiative. Departing Republican Governor Paul LePage refused to implement the expansion in spite of strong legislative support to do so, as well as an order from Maine’s highest court. In previous years, the Legislature failed by only a small number of votes to override LePage’s vetoes (5 times). Progressive forces expect to pick up state legislative seats on November 6th, so it’s also possible expansion could happen with a new Republican governor, supportive or not.
State Adoption Of ACA Medicaid Expansion (By Year)
SOURCE: Advisory Board. “Where the States Stand on Medicaid Expansion.” June 8 2018. Accessed Oct. 29 2018 at: https://www.advisory.com/daily-briefing/resources/primers/medicaidmap
Medicaid On the Ballot
Activists in three states—Idaho, Nebraska, and Utah—are standing in the wings hoping to be states #34, 35, and 36 depending on the outcomes of state ballot initiatives in each of them on November 6th. Montana has an initiative on the ballot to continue its expansion with dedicated funding.
While Idaho’s departing Governor Butch Otter fought consistently against Medicaid expansion throughout his tenure, he recently changed his position and announced his support for the Medicaid ballot initiative. Republican gubernatorial candidate Brad Little says he will respect the ballot initiative’s outcome—even though the measure does not specify how to finance the 10 percent financing match states will need to pay by 2020 (7 percent in 2019). Two organizations, Idahoans for Healthcare and Reclaim Idaho raised $594,191 by the late September reporting deadline, while the opposition Work, Not ObamaCare has raised $29,999. Idaho’s Hospital and Medical Associations contributed nearly $200,000 to the “yes” effort. Recent polling shows 66 percent support, including 77 percent from independents and 53 percent from Republicans. The yes campaign co-chair is Republican State Representative Christy Perry.
Nebraska previously did not have enough support to overturn a Governor’s veto against expansion. Nebraska Governor Pete Rickets maintains his opposition as he coasts toward an easy re-election. But it’s a spirited race for Nebraska Initiative 427, the Medicaid Expansion Initiative that would cover an estimated 90,000 low-income Nebraskans. The lead organization—Insure the Good Life—has raised $1.69 million as of late September to support a yes vote, versus $0 by the opposition Americans for Prosperity. The “yes” camp’s largest contributor is a national progressive political action committee called the “Fairness Project” which also backed the 2017 Maine Medicaid initiative and which has donated $1.19 million. Other key supporters include the Nebraska Hospital Association, the state health center association, Nebraska AARP and 24 other organizations.
Of the three ballot initiative campaigns, Utah’s is the most compelling. Proposition 3 would raise the state’s sale tax from 4.70 to 4.85 percent to fully finance the expansion for 150,000 low-income Utah residents. In 2021, that is projected to raise $88 million to cover the state’s projected $78 million share of the $846 million total expansion cost (the federal government pays the rest). A February 2018 poll showed 68 percent support among Utah voters. As in Nebraska, the national Fairness Project is driving the campaign, providing $2.7 of the $2.83 million raised as of late September. A wide array of health care and religious organizations are public supporters. No organization is registered with the state in public opposition to the initiative, as of late September.
To thwart the proposal, in March, Governor Gary Herbert signed House Bill 472 into law to expand Medicaid for individuals with household incomes no higher than 95 percent of the federal poverty line, as opposed to 138 percent in Proposition 3, as authorized under the ACA. HB472 would also impose work requirements on many enrollees and would cover 90,000 as opposed to the initiative’s 150,000. Earlier this year, the Trump Administration rejected a plan similar to HB472 that was advanced by Oklahoma to expand Medicaid eligibility no higher than 100 percent of the federal poverty level. So it is unclear whether the Trump Administration will allow the Utah HB472 expansion to go forward.
Montana is another state with a Medicaid expansion ballot initiative facing the voters on November 6th, but to continue the existing expansion. The state expanded Medicaid in 2015, though only through 2019. The November 6th ballot will present an initiative, I-185, to continue expansion past 2019 by raising tobacco taxes by $2 a pack as the state’s funding source. Healthy Montana for I-185 backers have raised $4.8 million and are battling the tobacco industry in the form of Montanans Against Tax Hikes (MATH) which has invested at least $12 million to defeat the initiative; 97 percent of the MATH’s money has come from Altria Client Services, maker of Marlboro cigarettes and other smoking products. If voters approve, the expansion will continue without restraints. If the referendum fails, the legislature still could pass a new funding law, likely with a work requirement attached.
Other Election Day Impacts
Of the 14 remaining non-expansion states, the November 6th results may have consequential impact. If Democratic candidates win currently competitive gubernatorial races in Florida, Georgia, Kansas, and Wisconsin, and pick up legislative seats, that could alter the Medicaid expansion equation. This would be especially true in Kansas where prior expansion efforts were thwarted by a narrow inability to override gubernatorial vetoes by only three votes. In other states, notably North Carolina with Democratic Governor Roy Cooper, significant Democratic gains in the state legislature may also have a consequential impact.
Some noteworthy features of this issue are worth considering. First, in many of these remaining states with Republican control, the price of expansion is likely to include work requirements on many newly eligible enrollees—as occurred in Virginia this past year. Unless ruled illegal by the federal courts, this national experiment will more than likely run at least for the duration of Republican control of the executive branch. As is apparent from the track record in Arkansas thus far, this is about values and ideology more than dollars and sense.
Second, after six years of fighting the Medicaid expansion wars, it is clear that most expansion opponents are not going to change their minds. Not much is left to say that hasn’t been said countless times before. As we saw in Virginia, a change of mind accompanies a change in occupants of legislative and gubernatorial seats. And in the four November 6th ballot initiative states, if successful, we should anticipate that one or more of the affected Governors may imitate Maine Governor LePage in seeking to block expansion in spite of voter sentiment.
Third, in spite of all the uproar, it is significant that not one expansion state has gone back on it, or even considered doing so. The closest an expansion came to a rollback was the election of hard right conservative Matt Bevin as Kentucky’s governor in 2015. Bevin abandoned his pledge to repeal Kentucky’s ground-breaking and successful Medicaid expansion early in his gubernatorial campaign, and never returned to that stance, turning to mandatory work requirements as the next best thing.
Much like how the public’s support for banning pre-existing condition exclusions has become calcified in the public’s mind from the battles of 2017 and 2018, similarly the expansion of Medicaid has become hard-wired into public consciousness in the states that adopted it.
I have yet to read an insider’s account on how and why the U.S. Supreme Court lined up 7 votes to secure their atrocious 2012 ruling to make Medicaid expansion an option for states. It is true that their decision played a role in compelling Americans to grapple with and understand the rationale and importance for Medicaid expansion. But at what a damn price!
In noticeable ways our current health reform period resembles the 2005-2006 era when political leaders, stakeholders, and think tanks began formulating proposals to prepare for a future national effort to achieve comprehensive health reform, a process that came to fruition with the signing of the Affordable Care Act (ACA) in March 2010. Though those years were also a time of unitary Republican control of the White House and both houses of Congress, many foresaw the arrival of a new president and Congress in 2009 as a potential and not-to-be-missed window of opportunity for important reform. Waiting until 2009 to begin planning would have been too late. I propose that in 2018 we embrace this renewed possibility for reform with realism and humility.
Today, we already see a plethora of legislative and policy proposals emerging from elected Democratic officials and progressive think tanks such as the Urban Institute and the Center for American Progress. While Sen. Bernie Sanders’s Medicare for All bill seeks the holy grail of single-payer reconstruction, others aim for meaningful yet incremental changes to address critical pain points in the current system.
All of these plans rely on an unreliable expectation that, come January 2021, Democrats will control the White House and governing majorities in the US Senate and House of Representatives, as the federal election cycles of 2018 and 2020 come to resemble the blue-wave cycles of 2006 and 2008. All of these plans recognize little potential for meaningful reform until then. However, if Democrats control all 3 power sources come January 2021, public demands on them for far-reaching national health reform may well be overpowering. Continue reading “Health Reform Realism”
[This new commentary was just published by the Milbank Quarterly.]
The years 2013 through 2016 were excruciating for the Massachusetts Health Connector. In 2013, the Connector was among the nation’s most troubled federal/state health insurance exchanges, as it endured an epic collapse of its new website to help consumers purchase individual health insurance. Since then, it has taken a step-by-step and low-key “no news is good news” approach to rebuilding trust and credibility with its 252,000 clients.
Now the silent period is ending. In 2006, Massachusetts was the first and only state to enact an individual health insurance mandate, the essential model for the federal individual mandate included in the Affordable Care Act (ACA) in 2010 and implemented in 2014. In last December’s Tax Cuts and Jobs Act, President Trump and Congress neutered the ACA mandate by reducing the financial penalty to 0. Despite widespread reports to the contrary, the mandate was not repealed, and the law, with its mandatory reporting requirements, remains on the books.
Thus, Massachusetts now returns to the spotlight as the nation prepares to examine the impact of the federal action, testing 1 state’s experience against that of the other 49. In 2015, the last year for which tax data is publicly available, only 3% of adult tax filers in Massachusetts reported not having insurance meeting state standards, corroborating other data sources indicating that it has the lowest rate of uninsurance in any state (the most recent US Census data shows Massachusetts at 97.5% coverage). Depending on an uninsured person’s household income, the monetary penalty ranges between $21 and $96 for each month without coverage. As of early February, at least 9 other Democratic-leaning states are considering adopting a similar mandate. Continue reading “Revisiting the Land of the Individual Mandate”
[This past week, I was one of the co-authors of a consensus policy paper on short-term steps that would stabilize the ACA health insurance marketplaces and address some other urgent health policy priorities such as reauthorization of the Childrens Health Insurance Program (CHIP). The paper was authored by a group of 9 policy experts (5 on the Republican/conservative side and 4 on the Democratic/progressive side). While the ideas are not revolutionary, we show that bipartisan consensus is possible and offers hope for saner and more balanced policy — we hope! Here is the paper below:]
The Congressional effort to repeal and replace the Affordable Care Act (ACA) has stalled, sparking urgent questions about what’s next and whether a bipartisan agreement could be achieved to address important U.S. health reform needs. We believe that critical matters relating to health reform must be addressed quickly and that bipartisan approaches are possible.
We are health policy analysts and advocates who join in this agreement. While we hold diverse political views and policy outlooks, we believe that health reform solutions exist that can transcend partisanship and ideology.
In this commentary, we describe our bipartisan agreement on five health policy matters that should be addressed by the end of the federal fiscal year, September 30. These recommendations are designed to provide stability in markets until a longer-term resolution can be achieved and, most importantly, to protect coverage and health care access for those relying on them now. Continue reading “A Bipartisan “What’s Next” for U.S. Health Reform”
Today is May Day and the ACA is still alive. Donald Trump’s campaign boast that he would sign a bill repealing the Affordable Care Act (ACA/ObamaCare) on his inauguration day is long gone and forgotten. House Speaker Paul Ryan and Senate Majority Leader Mitch McConnell’s gamble that by April 28th the ACA would be effectively decimated using the expedited budget reconciliation process proved to be a sucker’s bet.
Undeterred, White House and House operatives are trying by Wednesday to line up 216 votes—not to pass the Republicans’ American Health Care Act (AHCA) but to feign signs of progress to dampen the white-hot anger of the Republican base at their Party leaders’ inability to enact the ACA repeal promised since the law’s signing on March 23, 2010. They want to take a third run at it this week and perhaps succeed after two prior failures. Senate Republicans, meanwhile, are crossing their fingers hoping that the House fails, sparing the upper chamber the funerary duties. For the Senate to advance ACA repeal now, a new and wholly unimagined bill would need to be constructed.
The level of legislative malpractice evidenced by Speaker Ryan and his team since January is staggering and perplexing. They designed a bill that the Congressional Budget Office estimated would cause 24 million Americans to lose health insurance. They advanced a proposal that provoked public opposition from the American Hospital Association, the American Medical Association, the American Nurses Association, AARP, and hundreds of other national organizations representing Americans with serious stakes in our health care system. They invented a plan that generated unprecedented grassroots support for the ACA and fierce opposition aimed at them. For the first time, Ryan’s plan turned most Americans into ACA supporters. His legislation generated support from only 17% of Americans, an unheard of level of non-support.
Why did they do this and why do they persist?
Trump and Ryan both showed their hands in recent public statements linking ACA repeal with their tax cut agenda; Trump’s tax plan was released in one-page outline form this past week. To Republicans, the ACA’s poison is not the insurance expansion that bears remarkable resemblance to the two public health insurance programs they have always loved: Medicare Part C or Medicare Advantage, and Medicare Part D, the outpatient prescription drug benefit. Continue reading “MayDay! The ACA Is Still Alive and Still in Danger”
[This commentary, written by me and Dr. William Seligman of the Harvard Chan School, was published today on the Commonwealth Magazine website.]
IF PRESIDENT DONALD TRUMP and Congressional Republicans were to decide that fixing rather than destroying the Affordable Care Act, especially its private health insurance marketplaces, was in their self-interest, could they do it? And, could they do it in a way that aligns with Republican policy preferences?
The answer to both questions is “yes” – if Republicans heed lessons from their two favorite public health insurance programs. The programs are Medicare Part C, called Medicare Advantage, in which enrollees join private health insurance plans, and Medicare Part D, in which enrollees join private outpatient prescription drug plans.
While Republicans defend and brag about both of these reasonably successful programs, they may be surprised to learn that features of both point the way to successful stabilization and growth of the ACA’s private health insurance marketplaces. Here’s how.
Medicare Advantage: From Bust to Boom
Consider these two quotes:
“People’s premiums are going up 35, 45, 55 percent … The market is disastrous, insurers are leaving day by day, it’s going to absolutely implode.”
“They’re anguished, upset, frustrated and angry by the demise of their plans. … They’re facing increasing premiums and…plans are leaving the market.”
The first quote is President Trump talking recently about the instability of the ACA’s marketplaces. While most non-partisan observers disagree with the severity of his characterization, most – not all – of the federal, and some state, marketplaces are experiencing undeniable distress.
The second quote is from former congresswoman Nancy Johnson, a Connecticut Republican, talking in 2001 about the “Medicare + Choice” marketplace in which Medicare enrollees join a private health plan instead of participating in traditional fee-for-service Medicare (Parts A & B). Continue reading “A Republican Path to ACA Reform”
One of my favorite political scientists, Deborah Stone, wrote that much of the policy process involves debates about values masquerading as debates about numbers and facts.1 Although her construct is abundantly in evidence, it is being overlooked in the current debate over the future of the Affordable Care Act.
How much are premiums rising? How many plans are operating in the exchanges? How much money are accountable care organizations saving? What impact would a per capita cap financing scheme have on Medicaid? How much has the ACA restrained or propelled health cost growth? What do opinion polls show?
Each side furiously hurls data and anecdotes at each other as if by identifying the killer data point, the other side would throw up its hands in surrender and declare: “How could we have been so dumb?” Of course, this never happens in public policy debates. It never happens because numbers and anecdotes don’t motivate people on an issue as charged as the ACA. Values do. Continue reading “Health and Taxes and the Values at Stake in the ACA Debate”
GLOBAL HEALTH EXPERT Michael Reich says that the acid test of any national health reform comes when a new national administration takes over. Only when a new president or prime minister assumes power can we judge the stability and staying power of any health system reform. In the US, that’s this moment. Since November 8, we’ve been learning what parts of the Affordable Care Act (ACA) have staying power, which do not, and what’s uncertain.
Right now, after Friday’s demise of the Republican repeal and replace plan, the American Health Care Act (AHCA), we know that Medicare, Medicaid, insurance market reforms such as guaranteed issue, and delivery system reforms such as accountable care organizations look
safe. We know that the private insurance coverage reforms – insurance exchanges, premium and cost-sharing subsidies, the individual mandate – are at risk and in danger even though they dodged full repeal with the AHCA’s demise. And we don’t know the fate of the ACA’s many tax increases. Let’s view these systematically. Continue reading “The State of Play Post-Trump/RyanCare”
[This article was published on the website of the Harvard Chan School of Public Health in connection with an executive training program — Preparing for What’s Next in U.S. Health Reform — that I’m running May 31-June 2.]
by Lisa D. Ellis
These are uncertain times in American health care. The Republican Congress and President Trump have vowed to repeal and replace the Patient Protection and Affordable Care Act (ACA), commonly called Obamacare. They recently unveiled the American Health Care Act, the replacement plan, which has met with substantial resistance from all parts of the political spectrum. The current political and policy environment has left many health care leaders and other stakeholders wondering what to expect and how best to position their organizations for the next phase of health care reform.
The Potential Effects of Proposed Changes
House Republicans recently introduced legislation intended to create a new health plan, retaining some provisions of Obamacare and eliminating or scaling back others. While the exact details may continue to change in the coming weeks as the bill moves through Congress, there are some specific themes that can be expected in the final version that becomes law, according to John E. McDonough, DrPH, MPA, Program Director of Preparing for What’s Next in U.S. Health Reform and Director of the Center for Executive and Continuing Professional Education at the Harvard T.H. Chan School of Public Health. McDonough, who served as a Senior Advisor on National Health Reform to the U.S. Senate Committee on Health, Education, Labor, and Pensions, explains that there are two major components of the ACA that will be affected by whatever legislation is passed. These are access and value.
Two Main Themes: Access and Value
The first area, access, refers to insurance coverage for uninsured and underinsured Americans. While a significant impact of the ACA was that it expanded its Medicaid offerings to states to cover vulnerable residents, a number of Americans are now at risk of losing this support under whatever new plan is ultimately passed.
There are two major components of the ACA that will be affected by whatever legislation is passed. These are access and value.
“Many, many individuals have gotten health insurance coverage from ACA and [some of them] are quite concerned about whether they will still have coverage in three months, six months, or a year,” McDonough says.
The second area, value, refers to a focus started by the ACA to improve the quality, efficiency, and effectiveness of medical care in the United States. “The evidence shows Americans get care from our medical system that is not as high quality as we have a right to expect because of high costs,” McDonough says. The ACA established a number of initiatives to address this fact, including creating Accountable Care Organizations (ACOs), providing bundled payment plans, and imposing penalties on hospitals with very high rates of readmissions and hospital-acquired infections.
These types of efforts, which are part of a broader push to transform the health care delivery system to ensure a greater focus on value, are receiving widespread support from both Republicans and Democrats, which means that they should continue, and even grow, under any new health care law, McDonough stresses.
“There seems to be a growing sense in the health care community that [the move to value-based payment and population health management] pushed forward under ACA should continue and expand,” McDonough says, adding that this is one piece of good news in the sea of uncertainty that exists.
Preparing for New Developments
Ashish Jha, MD, MPH, Professor of International Health and Health Policy at the Harvard T.H. Chan School of Public Health, Director of the Harvard Global Health Institute, and a practicing general internist at the VA, agrees with this assessment. “The journey we began with ACA to move to value-based health care is going to continue,” he says. “But what form it will take, how we will do it, and how much is voluntary verses mandatory” remain to be seen moving forward.
He points out that this means that professionals need to know the range of options in order to be prepared for whatever way the field goes. “They need to ask, ‘What is the range and how do I prepare, so I will be in good shape?’’’ he explains.
Trends to Watch
Jha, who is also faculty on Preparing for What’s Next in U.S. Health Reform, points to a number of other changes also started under the ACA that, regardless of the final health plan passed, will continue to affect organizations over the next few years. For instance, people today are responsible for a growing portion of their own health care costs. This changes the way that organizations collect their money, meaning organizations need to find new ways of operating.
There will be many moral and ethical dilemmas for organizations as access shrinks and many patients lose coverage under the new plan.
“I think health care leaders are very used to a world where they provide services to patients and get paid by insurers, or the government/Medicare or Medicaid. But now they’re waking up to a new model where they are getting a larger chunk from patients. They’re not used to collecting money from patients themselves and that will change their relationships,” Jha says.
With customers footing more of the bill, they now have higher expectations from providers. “The customer is changing, and what will customers want in return now that they’re writing the check? That becomes a really important issue for providers to focus on. It’s part of patient-centered care. Now patients are in the driver’s seat,” he stresses.
Another issue worth paying attention to on the value side of the equation is that participation in some Medicare bundled payment programs will be voluntary for now, but is ultimately expected to become mandatory in the not-too-distant future. This raises some interesting questions for organizations, as they grapple with whether to use the voluntary program to get acclimated. Organizations that don’t participate now could end up having a lot of catching up to do in the future, which could “have very serious consequences three to five years down the road,” Jha says.
Issues to Watch
On the access side of things, Jha points out that there will also be many moral and ethical dilemmas for organizations as access shrinks and many patients lose coverage under the new plan. Five years ago, many people were uninsured and had no contact with the health care system. “Now, these people have been covered and have become part of the organizations [that serve them]. They have developed relationships with their doctors, so it’s a big difference now when they lose coverage,” he says. “Are organizations really going to walk away from these patients? [And if not], how will health systems manage the financial debt they will incur to care for the uninsured?”
Another important trend that will impact many health organizations moving forward revolves around consolidation. “Doctors are being bought out by big hospitals. We have no idea how the Trump Administration will feel about that. Consolidation is a strategy that provider organizations have used to survive, getting bigger. But that gravy train for providers is coming to an end. Now, with more people uninsured, and more focus on value, there are broader market issues around consolidation and integration that will be challenging for providers,” Jha says.
Other Trends Worth Following
Other trends that will continue to impact organizations include the growing push for providers to use interconnected Electronic Health Records (EHR). This is an important tool to help track and achieve key benchmarks of value-based care and improve coordination among providers for increased efficiency and better outcomes. “While everyone thinks this is a good thing, and most organizations have made the leap into EHRs, people, especially frontline doctors and nurses, are very frustrated with these systems. How organizations will manage the transition between simply adopting the EHR and using it in ways that lead to meaningfully better care is the challenge ahead,” Jha says.
In addition, Jha says that the Trump Administration’s tougher restrictions on immigration may have a real effect on health systems that needs to be addressed up front. “Twenty-five percent of doctors in our country are foreign medical graduates, as are a large population of our nurses and other health professionals,” he says. “As immigration gets tighter, there’s a question as to whether we will have a harder time attracting the best and brightest in the world. So health care will have a hard time building their ranks” in the future. With an aging population, this means that health systems may have challenges creating a good workforce to care for them.
The Importance of Staying Up-to-Date
With so many fluctuations expected in how the health care system will do business in the coming months and years, both Jha and McDonough say that it is crucial for health care leaders to stay abreast of the latest developments as they progress.
One of the most important things is for health care leaders to stay in touch with what is happening out there and pay attention to the coverage in the media.
“One of the most important things is for health care leaders to stay in touch with what is happening out there and pay attention to the coverage in the media,” McDonough says. “If you work in a hospital, [you will need to] follow the national organizations, such as the American Hospital Association, and stay alert to the opinions of experts as to what might happen,” he says. But that alone will not be enough, says Jha. Understanding the nuances of policy changes will be critical for leaders to stay on top of the shifting requirements—and opportunities—that exist in the current environment so they can strategically position their organizations for success.
Harvard T.H. Chan School of Public Health offers Preparing for What’s Next in U.S. Health Reform, which offers key lessons involving health reform from the nation’s leading policy experts under the new federal administration. To learn more about this opportunity, click here.