This week New Jersey's Chris Christie became the eighth Republican governor to recognize that only a chump would turn down 100 percent federal funding to provide Medicaid coverage to low-income constituents. But Governor Terry Branstad doubled down on his determination not to allow Medicaid to expand in Iowa.
While some advocates are hoping Republican legislators will help pass a Medicaid expansion bill by a veto-proof majority, that scenario appears extremely unlikely. A prolonged standoff between Branstad and Iowa Senate Democrats seems unavoidable.
At his regular weekly press conference on February 26, Branstad confirmed that he will ask the federal government for a waiver to expand and extend the IowaCare program, which is set to expire later this year. Rod Boshart reported,
Branstad said Iowa's Medicaid program would implement accountable care organizations that would provide a set annual fee and potential bonuses based on quality and available funding. He said the effort would include strong incentives for members to focus on prevention and personal responsibility in their health decisions.
"Just expanding Medicaid has not worked to improve health," he said, "in fact the health of the American people has gone consistently downhill. We've become more obese and less healthy."
Branstad said health care reform must increase the quality of care, lower costs and make Iowans healthier. He noted that Iowa Medicaid has grown from 250,000 recipients in 2000 to more than 400,000 Iowa adults now served - an expansion that grew participation by 65 percent and increased costs by 129 percent to more than $3.7 billion projected for fiscal 2014.
"Expanding Medicaid without any attention to the long-term funding of this program - both at the federal and state levels - fails the people that we really intend to help and it fails the hard-working taxpayers of Iowa and the United States that have to pay for it," he said.
Branstad said his administration is seeking flexibility to redesign the IowaCare program to best serve the health of Iowans.
According to Iowa's proposal, the IowaCare waiver program would cover Iowans below 100 percent of the federal poverty level and would require monthly contributions co-pays and deductibles which could be waived if preventative services are completed. The mechanisms are not intended to create financial savings for the state, but rather to encourage health and cost-conscious behaviors.
Right off the bat, you can see that Branstad's plan will exclude many people who would be covered under the Medicaid expansion. The 2010 federal health insurance reform law calls for everyone at or below 133 percent of the federal poverty level to be eligible for Medicaid. Branstad wants to cover only Iowans below 100 percent of the federal poverty level.
Several leading Democratic lawmakers met with the governor on February 27 to discuss the Medicaid expansion. Iowa Senate President Pam Jochum, Senate Human Resources Committee Chair Amanda Ragan, and Senate Health and Human Resources Budget Subcommittee Chair Jack Hatch told reporters afterwards that the governor said it will be at least two weeks before his administration has a plan to present. Because of the legislature's "funnel" deadlines, the House and Senate need to start moving bills through committee before then. Jochum said, "We asked for a bipartisan work group that would include Democrats and Republicans from both chambers, as well as the governor's staff, and the governor rejected that idea."
The governor and his people have a lot of work to do. They have a vague concept of what they want, but in our conversation with them, they were unable to answer some questions [that are] pretty basic to how we develop a program, how to work with the feds and how to deliver a new health care system to the state of Iowa. So we are hoping that they will get engaged with us. We're going to focus now on working with our colleagues in the Senate, Republicans and Democrats. [...]
We also are going to start working with our [Iowa] House colleagues, because we want them to know that they are welcome in developing something.
Radio Iowa's O.Kay Henderson asked whether Branstad indicated how many additional Iowans would be covered under his program. Jochum and Ragan said the governor didn't provide any details about that, or about how he would pay for his alternative to expanding Medicaid.
This week the Des Moines Register's editorial board called on legislators to bypass Branstad on this issue.
It is hard to imagine the governor's supposed "redesign" of IowaCare will be more comprehensive, or more financially sound, for the state, than comprehensive insurance under Medicaid that would be paid entirely by the federal government for the first three years. [...]
So now it is up to the Iowa Legislature to stand up for the people of Iowa - and to stand up to Branstad.
An Iowa Senate subcommittee last week took the first step toward that goal by passing legislation to expand the Medicaid eligibility to take advantage of the federal government's offer. The full Senate should get on board, too, and their counterparts in the Iowa House should do the same.
If Branstad vetoes the legislation, lawmakers should override that veto because, despite the political allegiance some lawmakers have to the governor, their allegiance should be to their constituents. Iowans need health insurance to be healthy. They don't want the taxes they are paying to the federal government to go only to help people in other states. Hospitals and doctors in Iowa should be compensated for providing care to poor people. That compensation has the potential of creating jobs in hospitals that have gone unpaid for treating the poor.
The Iowa Hospital Association is urging Iowans to contact Republican lawmakers about Medicaid, and so are other groups like the AARP, which notes that an estimated 17,204 Iowans between the ages of 50 and 64 lack health insurance coverage and would be eligible for the Medicaid expansion.
Under the Iowa Constitution, it takes a two-thirds vote in each chamber to override a governor's veto. In other words, at least 67 state representatives and 34 state senators would need to vote for a bill to expand Medicaid. In the Iowa House, 20 Republicans would have to join the 47 Democrats to override a veto--if House leaders even agreed to put a Medicaid expansion bill up for a vote. House Speaker Kraig Paulsen told the Des Moines Register's editorial board earlier this month,
"I don't right now see a scenario where we do the Medicaid expansion as defined in the ACA [Affordable Care Act]," Paulsen said.
The expansion could add an estimated 150,000 Iowans to the Medicaid rolls, extending health insurance to single individuals without children and those at slightly higher income levels.
The expiring program that Paulsen referenced as a potential focal point of legislative action on health care is the IowaCare program, which provides care to low-income individuals who don't qualify for Medicaid but which has more limited access points - requiring, for instance, patients to travel to either Des Moines or Iowa City for specialty care. Funding for the program is due to expire later this year.
Extending it is on the Republican agenda, Paulsen said, and that extension could reach "a significant subset" of the Iowans would be included in an expansion of Medicaid.
"I think we'll have that conversation, and try to make that system and the other Medicaid systems operate in a more effective fashion," Paulsen said. [...]
As for the IowaCare extension, House Majority Leader Linda Upmeyer said a proposal was in the works and could come up for discussion soon.
In the Iowa Senate, eight Republicans would have to join the 26 Democrats to override a veto. I haven't heard a single Senate Republican call for expanding Medicaid. The Senate Human Resources Committee vote on a Medicaid bill went along party lines. Iowa Senate Minority Leader Bill Dix has been like a broken record tweeting talking points against expanding Medicaid. Here are a few of his many comments on the subject.
February 5: "Expanding Medicaid in Iowa is a tough pill to swallow. The program has no measurable, outcome-based solutions."
February 13: "Wisconsin Gov. Walker declines Medicaid expansion. Without measurable outcomes-based solutions, Iowa should follow suit."
February 22: "Medicaid expansion is another step toward universal health care in America. Can we really afford it?"
February 25: "Glad we have a watchdog in @TerryBranstad as he recently sought answers from HHS Sec. Sebelius about Medicaid expansion."
February 25: "Is it responsible for Iowa to add an additional 150,000 people to a Medicaid program with no outcome based solutions?"
February 27: "Dems push Medicaid expansion through committee with little to no talk of fixing this program and no measurable outcome based solutions."
The state of Iowa is facing a very big decision. Should we opt-in to Affordable Care Act and face mountains of rules and regulations and the possibility that the federal government will not be able to follow through on their promise of funding. Should Iowa stay independent and follow through on its promise to deliver Medicaid to citizens and demand better health outcomes.
Currently, states are asked to opt-in to the system, essentially expanding Medicaid, enrolling more people and becoming dependent on the federal government for additional funding. This buy-in would cost billions and mandate that states meet many requirements for years to come. Expanding this program and being dependent upon the federal government is not a sound financial decision. We simply cannot count on the federal government to fulfill its promise.
Proponents will say that the benefit of the expansion is that the federal government will pay 100% of cost for the newly eligible person for the first three years. After that, the federal government will cover up to 90% for newly eligible persons. It is doubtful that the federal government will be able to uphold this promise. They are bankrupt. Federal government revenue totals around $12.5 trillion and expenditures total around $13.8 trillion. In order to balance the budget, the feds would have to cut around $1.3 trillion out of the budget. With a $1.3 trillion deficit and $16.4 trillion debt, it is hard to believe that they will be able to keep a commitment to fund Medicaid let alone the additional expansion costs. Any federal cuts to Medicaid will mean additional spending requirements for Iowa and make future funding commitments is next to impossible.
It is not reasonable to Iowans to continue to expand a system and to saddle the hard-working taxpayers with the ongoing expense. Iowans deserve a health care system that works for them and helps them become healthier. We should be working to fix the system and work to have a system with measurable outcomes before we choose to expand a program by nearly 150,000 people.
Iowa Senate Democrats sent out a press release yesterday vowing not to give up on "this opportunity to take a major step forward for Iowa," but is there any chance at all? Those who prefer to see the cup half-full may be encouraged by these comments from Hatch yesterday:
We told [Branstad] that we amended our bill today that included a lot of the programs that he had spoken about: prevention, personal responsibility, paying with outcomes. All of that is included in our bill. He was a little surprised and said that he liked that, and that there may be some things in our bill that he could incorporate. [...]
Mike Wiser, statehouse bureau chief for Lee Enterprises: What's to make people who want this Medicaid expansion, particularly some of these 150,000 people who would be added to the rolls, what's to give them any hope or indication that this will actually happen? Isn't this kind of false hope because the governor so far is not on board with this?
Hatch: There are eight Republican governors in the past four weeks who had the same position as the governor of this state who have changed their mind. We're hoping that they will begin to understand the financial impact to the state, and the opportunity to bring more people under health care insurance than ever before [...] We're not going to leave this place until we resolve this issue. [...] We are anxious to work with [the governor].
Could negotiations over the next few months give Branstad a fig leaf for changing his position? He could claim that he forced Democratic lawmakers to make Iowa's Medicaid program more accountable and outcome-based before agreeing to expand it.
Final note: yesterday the Iowa Hospital Association released a poll showing substantial public support for expanding Medicaid.
According to the poll, which was conducted by Essman/Research in Des Moines and funded by the American Hospital Association, 56 percent of Iowans support expansion while 32 percent said they are against it. Specifically, those polled were informed that an estimated 125,000-150,000 low-income adults would be covered under Medicaid expansion in Iowa. They were then asked, "Would you support the expansion of the Medicaid program in Iowa?"
In response to that question, a majority of adults in every Iowa congressional district supported expansion by a margin of at least 18 points. And while urban-dwelling Iowans are much more likely to support expansion (64 percent), a majority of rural Iowans (54 percent) also backs the idea.
Beginning in 2014, the Affordable Care Act (ACA) makes federal funding available to provide adults earning up to 133 percent of the federal poverty level ($14,856 for an individual; $30,657 for a family of four in 2012) with health coverage through Medicaid. Right now, the only non-disabled Iowa adults eligible for Medicaid coverage are parents at or below 82 percent of the federal poverty level.
The new poll shows Iowa Republicans are split over the question, with 43 percent in support and 45 percent against. However, when asked if Iowa should expand Medicaid to prevent losing the state's share of federal funds to other states, far more Republicans support expansion (47 percent) than oppose it (37 percent). Whether to provide insurance to more needy Iowans or to ensure Iowa gets its share of funding, better than eight out of 10 Democrats support expansion. [...]
One benefit of expansion is that more Iowans will receive coverage for mental health care. According to the survey, more than three out of four Iowans, including 74 percent of Republicans, believe better access to mental health benefits is needed in the state. [...]
Medicaid expansion would also provide more Iowans with access to preventive health care, such as yearly physicals, immunizations and diagnostic testing. According to the survey, nine out of 10 residents believe that every Iowan should have access to these benefits. [...]
To gather data for the poll, Essman/Research conducted 502 random telephone surveys in early February with Iowans age 19-64 years old in all 99 counties. Essman/Research developed the questionnaire and the random sample, collected the survey data, coded the open-ended verbatim responses, analyzed the data and prepared the survey report. On the total sample of 502 random telephone surveys, at the 95 percent confidence level, the maximum margin of error is +/- 4.4 percent.
Cautionary note: the American Hospital Association, which commissioned this poll, strongly supports the Medicaid expansion as a way to reduce the amount of uncompensated care hospitals provide. A survey commissioned by another advocacy group found a similar margin of support for the Medicaid expansion in Iowa. The Des Moines Register's latest statewide poll conducted by Selzer & Co. found Iowans more evenly divided over expanding Medicaid.
Please share any relevant thoughts in this thread.
LATE UPDATE: "Two weeks" turned out to be an exaggeration. Branstad rolled out his "Healthy Iowa Plan" on March 4.