Monday, June 12, 2017

Senate "moderates" promised long ago to support the ACA repeal bill in progress

I keep reading that Senators Capito and Portman and Heller, relative Republican "moderates" from states that have embraced the ACA Medicaid expansion,  have reversed themselves by signaling willingness to repeal the expansion if the repeal timeline is stretched out.

Capito may have made some contradictory noises over the last few months, occasionally indicating that she does not want to see the expansion repealed.

But look again at the letter to McConnell that Capito and Portman signed onto just before the House repeal bill, the AHCA, was released.  That letter, which was read as defense of the Medicaid expansion, demanded
that any health care replacement provide states with a stable transition period and the opportunity to gradually phase-in their populations to any new Medicaid financing structure.
In Republican-speak, that means expanding the timeline in which enhanced federal funding for the Medicaid expansion population is phased out -- as the Senate bill will do. I examined the letter's consistency with the course the Senate is undertaking now in more detail in this post.

You can accuse these senators of selling out their constituents, ensuring that Medicaid won't be available to those who fit the expansion eligibility criteria but not previous criteria within a few years -- and also ensuring that all Medicaid programs will be steadily degraded by per-capita caps. But you can't accuse them of reversal or inconsistency.

Ditto for Heller. Here's what he said in a closed-door meeting with constituents on March 11:
“They’re talking about 2020, now they’re talking about making the changes in 2018,” Heller said. “That’s not enough time for Nevada to adjust. We need time to adjust. I want to move that thing up four or five years," he added, referring to a longer delay. 
Defending Medicaid? That's about as squish as you can get.

There has always been a fingers-crossed aspect to Republican promises to protect the Medicaid expansion population. They have promised not to pull the rug out from anyone, or uninsure anyone. And indeed, their bill retains the enhanced federal match for Medicaid expansion enrollees who remain enrolled after the cutoff for new enrollees.

These promises elide the fact that Medicaid enrollees habitually step on and off the rug at short intervals, as CPBB's Matt Broaddus and Edwin Park explain:
Most adult Medicaid enrollees see their incomes fluctuate and thus use the program for relatively short spells, so the higher state costs would apply to most of a state’s expansion program within just two or three years.  Moreover, while under the ACA, states must redetermine eligibility for expansion adults annually, the AHCA would require them to do so every six months starting in October 2017, which would accelerate the declines in enrollment.  More frequent eligibility redeterminations have been found to lead many eligible people to experience coverage gaps if, for example, they move and don’t receive their redetermination paperwork in time.

CBO estimates that more than two-thirds of those enrolled in the Medicaid expansion at the end of 2019 would fall off the program by the end of 2021 and that fewer than 5 percent would remain on Medicaid by the end of 2024.
And as for the "stable transition period" and "time to adjust" that the "moderates" demanded -- and will, to some degree get -- it doesn't help much (Broaddus and Park again:
Delaying implementation until 2022 would only modestly increase the number of grandfathered enrollees receiving the expansion match to 300,000 of the total 11.1 million current Medicaid expansion enrollees — fewer than 3 percent of them — by the end of 2027. 
The "moderates" positioned themselves to sell out the working poor -- and that's just what they're doing.

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