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Unexpected legislature resignation tips Virginia fight over Medicaid expansion

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    The battles over whether to expand Medicaid coverage under the federal health care law are still playing out in a number of states this summer, the latest, Virginia, where Republicans in the state Senate grabbed control of that chamber yesterday, and prevented Governor Terry McAuliffe, a Democrat, from opting into the expansion.

    It happened after another Democrat, a state senator, unexpectedly resigned amid claims that he was trading his seat for another position and an appointment for his daughter.

    Meanwhile, there are a handful of states, including Indiana, Pennsylvania and Utah, where Republican governors are considering participating in Medicaid expansion, but only with more requirements and restrictions from those who would be covered.

    So far, 26 states, plus the District of Columbia, have agreed to expand. The Obama administration says six million people have gained Medicaid coverage. But there may be nearly two million waiting for their applications to be processed.

    Julie Rovner, who is now with Kaiser Health News, joins us now.

    And welcome back to the program, Julie.

  • JULIE ROVNER, Kaiser Health News:

    Nice to be here.


    So, why have some states still not made a decision about whether to expand Medicaid?


    Well, of course, they don't have to. In 2012, the Supreme Court said that this was optional. This, of course, was not going to be optional as the health law was passed.

    The health law expected and anticipated that every state would expand Medicaid. Congress of course knew when it passed the law in 2010 that states didn't have a lot of extra money lying around to help pay for Medicaid, which is of course a shared program between federal and state governments. Basically, the federal government pays a little more than half of the cost for it.

    But the federal government said that for this expansion population, they would pay 100 percent of the cost for the first three years and it would phase down to 90 percent, so it would still be most of the cost going into perpetuity, but when the Supreme Court made it optional, half the states, as you pointed out, jumped in, and the other half, most of them Republican states, have said, we don't even know if we can afford that 10 percent that we would have to kick in after the three years, when it's going to be, you know, fully federally funded.

    So, they're still arguing about in the states.


    And as we were just pointing out, in one of these states where it's on the cusp, they're trying to figure out what to do, Virginia, with a new Republican governor, having had…


    A new Democratic governor.


    I'm sorry, a new Democratic governor, having had a Republican governor — the state legislature, state Senate, now has this switch, a very unusual situation there.



    Well, of course, the new Democratic governor ran with this as his number one priority to expand Medicaid, and, of course, it's a Republican House, and it was a split. The Senate, it was 50/50, with, of course, the lieutenant governor being the deciding vote. So this one resignation by this state senator has slipped the state Senate to the Republicans.

    And basically there's this budget standoff. And it could have — it was thinking that it was going to close — shut down the state over the budget. Now, of course, it looks like the budget will not have the Medicaid expansion it in, much to the dismay of the Democratic governor.


    Terry McAuliffe.


    There is still a possibility — that's right. There is still a possibility that there could be a special session, that Medicaid could come back.

    There are a couple of moderate Republicans in the Senate who do support the Medicaid expansion, but certainly it puts it in much more doubt, just with this one expected and unknown-why resignation.


    But when — but then you have, Julie, these other states that are trying to figure out, Republican governors, Utah, Pennsylvania, Indiana, just to name a few of them, politics peculiar to each state in play in every one.


    Yes, and we're starting to see kind of a theme with these Republican governors who would like the federal money.

    It's a lot of money for a large uninsured population in many of the states. Pennsylvania has perhaps 400,000 people who could be covered. And what many of these Republican governors are doing — we have seen this in Iowa already — is they're saying, OK, we want to expand Medicaid, but we want to do it our way. So we want to have perhaps these people go into private plans. We have already seen that in Arkansas.

    We want to have these people perhaps pay a little bit more in cost sharing, so have this low-income population pay something for their coverage. That's not traditionally been allowed in Medicaid. And we want to have perhaps incentives for them to have — do healthy behaviors, maybe stop smoking or lose weight.

    So those tend to be the kinds of things they're asking for, and they haven't necessarily got that yet from the federal government.


    And what is the pushback that you're hearing from advocates for the poor, who say even a small amount that some of these folks are required to pay can prevent them from having access?


    Well, there's a large body of research that suggests that cost sharing does deter people from getting care and it particularly deters poor people from getting care. And there's a concern that if — that even if you put small amounts of cost sharing on, that people who need care, particularly people with chronic ailments, won't get that care, so it can be counterproductive

    And they're very concerned about the idea of having — quote, unquote — "skin in the game" for the Medicaid population in particular.


    So while those dramas play out and with very real consequences, just quickly, Julie, this notion that there are several million people who have applied for Medicaid don't have their applications responded to yet.


    That's right. And this is partly because in putting in the Affordable Care Act, every state had to change the way it calculated eligibility for the Medicaid population.

    This was to basically make it standardized across all of the states. And so basically, as of January 1, every state had to change the way it calculated eligibility. Also, there was some difficulty in healthcare.gov, the Web site, reporting — basically sending the information to the states and getting it back and forth.

    So there is this backlog. Most of it turns out to be in California and Illinois, two big states. This was some work done by my Kaiser Health News colleague Phil Galewitz. But there's also a backlog, it turns out, in some states that didn't expand Medicaid, states like North Carolina, and Georgia. Hopefully, just over the next few weeks, as these states get their I.T. problems straightened out, the backlog will dissipate, if not go away.


    Julie Rovner, always on top of it, thank you very much.


    Thank you.

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