In which Idaho offers a quarter loaf to its uninsured poor

Thanks to Dylan Scott for flagging a draft ACA innovation waiver proposal published by the Idaho Department of Insurance this past November. Someone in the ensuing Twitter stream called the proposal "creative" -- and it is, in the sense that repeal of the ACA individual mandate is creative. That is, it "saves" money by insuring fewer people at higher per-person cost than the ACA default structure -- in this case, proposing a private alternative to Medicaid expansion.

More specifically, the proposal would newly insure one fifth as many Idaho residents as would Medicaid expansion at about one third of the added cost. That's notwithstanding the fact that while Medicaid expansion would cost about $300 million more per year in total than the status quo arrangement, the federal government would pay five sixths of the added cost.*

That's genuinely creative when you allow that the more cost-effective alternative -- Medicaid expansion -- has proven to be a political impossibility in the state. It's also an implicit confession that a Republican state government prefers to spend more per person while leaving a larger percentage of its population uninsured -- without any attempt to argue that the more-expensive insurance is better for enrollees or yields other social (as opposed to ideological) benefits.

Could a Clinton HHS entice more Medicaid expansions?

When I was 19, I spent a summer on an archaeological dig in New Mexico. Work groups were mainly led by grad students in archaeology, and I recall someone telling the tale of a Ph.D thesis (not hers) that devoted 600 pages to demonstrating that an artifact dating technique did not work. She said,
somewhat ruefully, something to the effect of, "that's supposed to be useful too."

Below, I want to devote 600 words to an ACA-strengthening proposal that probably won't work. Writing 500 words before realizing this probably has something to do with the decision. But maybe floating it is useful. Maybe it suggests some variation that might work.

The context: I was combing Hillary Clinton's raft of healthcare reform proposals for measures that might be enacted without legislation.  In a prior post, I looked at her proposal to help states form public options in their ACA marketplaces. Next up:

Entice states that have refused the Medicaid expansion to embrace it. Clinton's healthcare page reiterates an Obama administration proposal to "to allow any state that signs up for the Medicaid expansion to receive a 100 percent match for the first three years." That was the original plan, with the federal share dropping in stages to 90% thereafter. But that was beginning in 2014. By statute, at present, states that opt in late don't get the full three years of full reimbursement.Beginning in 2017, the federal contribution to the cost of the expansion starts phasing down to a mere 90%, regardless of when the state implemented (or will implement) the expansion. Altering that would require legislation.

Will the ACA reduce the disability rolls?

Two years ago, I was riveted by TNR reporter Alec MacGillis' chat with a woman on line for a free REM medical clinic in rural Tennessee. Notwithstanding that she knew nothing about the ACA, she offered a stunning instant analysis, once the basics were described to her, of one likely economic effect:

..it it was hard to find visitors to the clinic who would not benefit directly from the law. Barbara Hickey, 54, is a diabetic who lost her insurance five years ago when her husband was injured at his job making fiberglass pipes. She gets discounted diabetic medication from a charity, but came to the clinic to ask a doctor about blood in her urine.

Under the law, she would qualify for Medicaid. Her eyebrows shot up as the law was described to her. "If they put that law into effect, a lot of people won't need disability," she said. "A lot of people go onto disability because they can't afford health insurance."

Lo, Ms. Hickey was a prophet (perhaps). In Arkansas, which has sliced its uninsured rate almost in half since ACA enactment, mainly by enrolling nearly 200,000 Arkansans in the state's "private option" Medicaid alternative, disability claims seem to be dropping.* Modern Healthcare's Paul Demko reports:**

Raymond Scheppach: States wll take back their ACA exchanges (eventually)

Raymond Scheppach, longtime director of the National Governors Association (1983-2011) and a former deputy CBO director, is an expert on the role of the states in the formulation and implementation of public policy.  Currently a professor at the University of Virginia, he recently served as project director for a report, Cracking the Code on Health Care Costs,  produced under the auspices of UVA's Miller Center by a State Health Care Cost Containment Commission co-chaired by Michael Leavitt, former Republican Governor of Utah and HHS Secretary under George W. Bush (interviewed here), and Bill Ritter, former Democratic governor of Colorado.

The report highlights the power of state governments to shape healthcare policy, given their roles administering Medicaid, state employee benefits, and now the health insurance marketplaces established by the Affordable Care Act.  It calls on states to set targets for health care spending; promote various forms of managed care, ACOs and alternatives to fee-for-service medicine in the programs it administers; and help consumers generate competition by reporting cost and quality information about health care providers and insurers.

I spoke to Dr. Scheppach, now a professor of public policy at UVA, about current and likely future state-level healthcare reform efforts.

Scheppach noted at the outset that  state governments administer or oversee health insurance for a large swath of the U.S. population  -- with more to come as the ACA exchanges and Medicaid expansion matures. "If you add it all together, in another year or two, there will be about 75 million people in Medicaid, another 3-5 million in state and local government employees' health plans, and then there's the exchanges." (CBO projections envision 25 million ACA exchange customers by 2018.)

Red state attitudes toward the ACA: like America's, but more so

Update, 4/25:  see next post re the high rate of pre-existing conditions reported by respondents to this poll.

A New York Times/Kaiser Family Foundation poll released yesterday probes perceptions of the Affordable Care Act in four red states, Arkansas, Kentucky, Louisiana and North Carolina. * In all of these states, Obama's approval rating is in the 30s, and the ACA is also deep underwater, with approval/disapproval percentages ranging from 29/62  in Arizona to 38/54 in North Carolina.*

Those overall judgments, stoked by five years of relentless Republican denunciations and a barrage of negative advertising in recent months, are stark.  And yet, the underlying attitudes revealed in the poll's internals are strikingly congruent in key respects to the attitudes toward prospective healthcare reform recorded nationally in a Kaiser poll conducted in December 2008, when approval for a president-elect who had campaigned on a national healthcare overhaul was sky-high. 

In both polls, majorities opposed simply maintaining the pre-ACA status quo -- doing little or nothing to expand coverage in 2008, repealing the ACA today. In both, majorities favored government action to make health insurance available to people who could not get it from their employers. In both, majorities supported expanding Medicaid.  Yet in both, majorities rejected the notion that it was the federal government's responsibility to make affordable healthcare coverage available to all Americans.

Obamacare to be repealed and replaced in 2017...

In at least one state, that is.

Almost everything that Republicans who profess to want to reduce the ranks of the uninsured on the ACA's scale say they want to do can be done via state waivers effective 2017.

Here is a summary of ACA Sec. 1332, Waiver for State innovation, from an ACA outline posted on the Democratic Policy and Communication Center website:

Beginning in 2017, allows States to apply for a waiver for up to 5 years of requirements relating to qualified health plans, Exchanges, cost-sharing reductions, tax credits, the individual responsibility requirement, and shared responsibility for employers. Requires States to enact a law and to comply with regulations that ensure transparency. Requires the Secretary to provide to a State the aggregate amount of tax credits and cost-sharing reductions that would have been paid to residents of the State in the absence of a waiver. Requires the Secretary to determine that the State plan for a waiver will provide coverage that is at least as comprehensive and affordable, to at least a comparable number of residents, as this title would provide; and that it will not increase the Federal deficit.

Children, CHIP, Medicaid and the ACA

Means-tested government benefits are inevitably a somewhat blunt instrument. One inflexibility in the Affordable Care Act is its propensity to put children into CHIP and young adults into Medicaid.

Every state has its own threshold for CHIP eligibility, which the ACA incorporates into its calculations. If the state threshold is 300% of the Federal Poverty Level (FPL), then any ACA applicant in that state with children and an income under that benchmark will find their children enrolled in CHIP, while the adults select a subsidized plan from the exchange. A family with CHIP-eligible kids can enroll the whole family in an exchange plan, but the kids will be unsubsidized, according to the Kaiser Family Foundation.

Likewise, a lot of young adults, including most college students, will have an income that qualifies them for Medicaid -- that is, below $15,521 in 2014 --  and so will not be able to get a subsidy for a private plan if it better suits their needs.