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Wednesday, January 9, 2019

Medicaid Expansion at the Top of State Legislative Agendas

Patrick Willard

Senior Director of State and National Strategic Partnerships

State lawmakers this year face an array of decisions on health care coverage under Medicaid. Following the passage of ballot initiatives in 2018, the largest number of states are expected to take up plans to expand Medicaid since the Supreme Court ruled in 2012 that the new health care provision was optional.

Three states lead the pack after ballot wins. Idaho, Nebraska and Utah will first meet requirements to file their plans with the federal Centers for Medicare and Medicaid Services (CMS). Those efforts will expand Medicaid coverage to an estimated 150,000 Utahans; Idaho will expand coverage to approximately 62,000 people, and an estimated 90,000 people will gain access to health coverage in Nebraska. Lawmakers in each state are expected to then weigh-in on funding and eligibility requirements for the program.

In addition, three new governors that supported Medicaid expansion are expected to make a push for health care coverage. Gov. Janet Mills of Maine began her term with an executive order to implement the expansion plans that were put on hold by outgoing Gov. Paul LePage last year. In Kansas, Gov. Laura Kelly is weighing the prospects for expanded coverage as she prepares for her first legislative session. Newly-elected Wisconsin Gov. Tony Evers is also examining how the state can benefit from expansion. Wisconsin currently provides coverage to most expansion-eligible adults, but by virtue of not fully implementing expansion Wisconsin has missed out on the 90/10 rate enjoyed by expansion states.

Gov. Roy Cooper of North Carolina is also considering expansion in a legislature that no longer has a supermajority of Republican lawmakers. Finally, Gov. Phil Bryant of Mississippi is reported to be discussing increasing health care coverage, but has not made any public commitment.

Families USA worked with state groups including the Utah Health Policy Project, Idaho Voices for Children and Nebraska Appleseed to make the case for the Medicaid expansion in the November elections. The referendum wins brought the number of states expanding Medicaid up to 37, including the District of Columbia.

Under the 2018 ballot measures, Utah was the only state that provided funding. Revenue from a 0.15 percent sales tax will provide the 10 percent matching share to draw down the 90 percent federal funding for the Beehive State’s expansion. Medicaid officials are moving forward with plans to meet the requirement to file a state plan amendment (SPA) with federal officials by the April 1 deadline to begin expansion in July.

Idaho is expected to file its federal expansion state plan amendment (“SPA”) in February for a program that will take effect in 2020. Nebraska will move ahead with a SPA in April for an expansion slated to begin in July. Both states will have to identify the 10 percent in state matching funds in budget deliberations during the upcoming legislative sessions.

State lawmakers may also consider proposals to limit access to health care coverage by creating a series of restrictions and red tape for eligibility. Trump administration officials have already approved restrictions in some states, but the access limits have only been actually tested in Arkansas, where some 17,000 low income individuals have lost coverage in the final three months of the past year.  These restrictions were held up by the federal courts in the first state to try to implement them—Kentucky—and there will be a court challenge to Arkansas’s program in the next few weeks and likely to those of other states trying to implement in 2019.

Lawmakers in New Hampshire—who designed their own Medicaid restrictions--are objecting to tougher restrictions imposed by federal officials as part of a waiver approval for the Medicaid program. The “community engagement” provisions added by CMS will make it harder for eligible individuals to maintain health care coverage. These restrictive measures will also add to the costs of the program with increased eligibility requirements and notices.

The latest in Medicaid waiver proposals can be viewed at the Families USA Waiver Strategy Center.  The site provides details on waivers submitted to CMS and their progress. The center also provides tools for advocates to submit comments on waivers and coverage restrictions.

The momentum for Medicaid expansion could make the 2019 legislative sessions the most successful for increased health care coverage since the 2016 elections. The debate over how those programs will be structured is likely to playout in the sessions in both expansions and non-expansion states.

For more information about Families USA's efforts to help states implement expansions of their Medicaid programs, please see read about the Medicaid Expansion Leadership Team (MELT) and see our Medicaid Expansion Toolkit