Editorial: Here’s hoping for a Medicaid compromise
The parallels are inescapable. New Hampshire’s governor and Legislature are in a position akin to that of Congress and the president in the days before the recent government shutdown. The stakes here are not as high, of course, but should Democrats and the Senate’s Republican majority fail to compromise on a plan to expand access to health insurance for the poor under Medicaid, several very bad things will happen.
Some 60,000 or 70,000 people now uninsured will continue to go without coverage. The cost of the care the uninsured do get in emergency rooms will continue to drive up the cost of premiums for everyone else. And the state will forfeit between $500,000 and $1 million per day in federal money that would otherwise provide health care and boost the economy.
Gov. Maggie Hassan, House Democrats and Senate Republicans only have a few more days to get to yes on a plan to expand access to Medicaid to adults with incomes up to 138 percent of the poverty level. On Thursday, the special legislative session convened to consider expansion will end. If no agreement is reached, there will be no way to take advantage of the Jan. 1, 2014, date when coverage under the Affordable Care Act begins.
The two sides are close to agreement, and the plan that emerges will closely mimic one drafted by Senate President Chuck Morse and Majority Leader Jeb Bradley. Quibbles remain. The Morse plan, for example, gives oversight of the huge pool of federal money to subsidize insurance to a committee whose majority will be representatives of organizations that will receive that money: health care providers. Critics of the Senate plan have a long list of similar concerns, but none appear to be an impediment to progress. The timing of the Senate plan however, is a potential deal-killer.
Implementing Obamacare and expanding access to Medicaid, let alone doing so under an as-yet unwritten plan that requires federal approval, is enormously complicated. Almost every part of every endeavor is in flux. So without getting into the deep weeds, the sticking point is this: The governor and the House want the people newly eligible for Medicaid to be able to obtain coverage under the standard Medicaid programs now being overseen by three managed care companies until at least 2017 before shifting them to private plans with what amounts to a voucher to subsidize the cost. The added time could allow players other than Anthem, the only insurer signed up to participate in the health care exchange marketplace, to join, thus increasing competition and lowering costs.
The Senate proposes a timeline hinged on federal approval of the one piece everyone agrees on: People with access to insurance through their employer should use that instead of Medicaid, with financial assistance to pay their portion of the premium. Once that program’s approved, likely before April, Bradley’s plan starts a 365-day countdown to moving the other newly eligible people off managed care and onto the exchange.
Morse believes it is important to push patients into private insurance plans as quickly as possible. The governor, several Democratic senators and House Democrats, say the one-year deadline is wildly unrealistic and, if met, could result in a flawed system created in haste.
Democrats aren’t convinced that federal Medicaid authorities will grant all the permissions needed at all, let alone on Morse’s rushed timetable.
Morse cites the rapid approval of a similar waiver received by the state of Arkansas, but he neglects a couple of key differences. One is that Arkansas worked on its application for a full year before submitting it.
The other: Few states have milked the Medicaid system out of as much money, relative to their size, through the so-called Mediscam hospital reimbursement scheme as this one. Any request to allow New Hampshire to play by special rules will get extra scrutiny in Washington.
For that, and a host of other reasons, Morse’s deadline could indeed mean that come this time next year, newly insured poor will be told that their coverage ends on New Year’s Eve.
In a recent meeting with Monitor editors, Bradley seemed open to considering a more lenient timetable. We hope his fellow senators are as well, because Morse’s deadline won’t work.