Semro column: The battle over Medicaid
Here’s something to think about before November. Even though candidate Trump promised to defend Medicaid and protect its funding, his administration in partnership with 13 states, controlled by Republican governors and state legislatures, are waging a not-so-covert war on that program. And that effort is putting this lifeline for millions of Americans at risk.
Medicaid and the Children’s Health Insurance Program provide coverage to 73.7 million Americans including working class and lower-income adults, children, pregnant women, seniors and people with disabilities. Medicaid is jointly funded by the states and the federal government, with the states administering the program according to federal guidelines.
For many working-class and lower-income Americans it’s the only affordable coverage available. And if you’re older than 65 and can’t afford long-term care, Medicaid is your only safety net.
After the passage of the Affordable Care Act, 33 out of 50 states including Colorado and the District of Columbia expanded Medicaid eligibility to all citizens with incomes under 138 percent of the Federal Poverty Level. That’s an annual income of $16,753 for an individual or $43,304 for a family of four. By 2016, 15.1 million previously uninsured Americans got coverage through these expansions.
According to the Kaiser Family Foundation, 856,000 Colorado citizens got their health coverage through Medicaid In 2016. Colorado’s Medicaid expansion covered about 451,000 of that total. That also included 251,000 childless adults who were ineligible for Medicaid coverage in Colorado prior to the expansion.
But what’s most important for the rest of this discussion is that in Colorado, 75 percent of non-elderly Medicaid families have at least one full-time worker and 11 percent work part-time. Those who don’t work are often in especially vulnerable populations like the chronically ill, seniors, people with disabilities, family care-givers and the very poor.
And that’s where the new battle begins.
The Trump administration has clearly signaled to states that they’re open to unprecedented policy changes through something called an 1115 waiver. These changes could set in motion some of the most dramatic reductions in enrollment and funding since Medicaid became law.
Four states, Kentucky, Indiana, Arkansas and New Hampshire have had their waiver proposals approved by the administration and nine others have applications in the pipeline. Under some of these proposals states can impose work requirements of 80 hours a month on expansion adults and low-income parents.
Even enrollees exempt from work requirements may still have to document their exemption status and adults who are already working also will have to document and report their hours. States can charge monthly premiums up to 4 percent of income and impose multiple coverage lockouts for enrollees who fail to pay premiums or renew coverage in a timely manner. States can impose eligibility term limits. And they can eliminate retroactive eligibility for most adults, including expansion adults, low-income parents, and people who are medically frail. They also can waive non-emergency medical transportation for most expansion adults.
On June 28, the U.S. District Court for the District of Columbia ruled against the Kentucky proposal describing it as “arbitrary” and “capricious,” leaving that state’s effort on hold. The court decision also highlighted the fact that the federal Department of Health and Human Services didn’t even address whether Medicaid beneficiaries would lose coverage as part of their 1115 waiver approval process.
Nevertheless, other states continue to pursue their waiver proposals and an appeal against the Kentucky decision is in the works.
According to a study from the Kaiser Family Foundation, between 1.4 and 4 million Americans could lose Medicaid coverage if all states imposed these requirements. And that could happen since Republican congressional leaders are thinking about mandating federal Medicaid work requirements in every state should they keep control of the House of Representatives.
As for “purple state” Colorado, in 2017 and 2018 Republicans at the State Capitol introduced legislation to repeal the expansion of Medicaid (Senate Bill 17-003) and implement Medicaid work requirements (Senate Bill 18-214).
If Senate Bill 003 had passed, existing coverage for 451,000 Coloradans could have simply ended without any viable alternative.
Senate Bill 214 would have imposed Kentucky-like work requirements in Colorado and would have required enrollees to verify their income each month in order to stay eligible. The bill would have established a lifetime, five-year limit on Medicaid benefits, as well as require enrollees to pay co-pays for emergency room use and transportation for non-emergency services.
If it had passed, Senate Bill 214 would have done little to cut costs (between 1 and 1.5 percent of Colorado’s Medicaid budget in 2021). But for those who could have lost coverage, the bill would have had serious and lasting consequences. For thousands of Coloradans, the emergency room, the most expensive form of health care, would have once again become their primary care provider.
If the Governor’s office and the legislature change hands in Colorado, this could be the future.
Bob Semro of Glenwood Springs is a former health policy analyst for the Bell Policy Center, and a legislative and senior advocate.
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