Voters are pushing their representatives to stop their fighting over Medicaid expansion. People want and need the same medical coverage available in other states.
Millions of people were left out of equal access to care when the ACA took effect. This was mainly because of partisan politics, with Republicans framing Medicaid as another form of public welfare.
Voter initiatives to expand Medicaid over the wishes of their elected representatives have been picking up steam.
It is one thing to pass a referendum and another thing to get stubborn minded politicians to honor it.
♦ Of the 12 states that have yet to expand Medicaid; only Florida and Wyoming allow voter initiatives or referendums.
• Mississippi's constitution requires initiative sponsors to gather signatures from five congressional districts but the state has had only four districts since the 2000 census.
► On November 8th, South Dakota voters approved a constitutional amendment to expand Medicaid starting July 2023. The number of holdout states will drop to 11 at that time.
• Out of these 12 states, 11 of them have the highest uninsured rates in the nation. To make things worse, more rural hospitals are closing in these states than anywhere else in the country. Their leaders seem oblivious to both crisis.
Missouri and Florida tried to make it harder to introduce ballot initiatives.
Missouri failed to prevent a ballot initiative on August 4, 2020. The voters approved the initiative but Governor Mike Parson tried to prevent its implementation.
The Missouri Supreme Court ruled against the governor and ordered the state to proceed. Missouri began implementing the expansion by accepting applications on August 10, 2021 with coverage to be retroactive to July 1, 2021.
♦ Florida's legislature first succeeded in delaying a ballot initiative in 2019. In 2020, the Florida legislature then changed the rules of the game by passing SB1794. This bill raised the signature threshold requirement for the initiative and at the same time specified that any signatures would remain valid for only one year.
The sponsors of the original initiative had collected just under 82,000 signatures. The new rules now required 222,898 signatures collected from 50% of all congressional districts not 25% as in the years past.
• In 2020, the Florida Senate then asked the Florida Supreme Court to invalidate the initial initiative due to lack of signatures. The court agreed and the initiative failed.
A number of states have expanded Medicaid but only partially. These states operate under what is called a Section 1115 waiver from the Centers for Medicare & Medicaid Services CMS).
A partial expansion usually means they cover less people then a full expansion. The state will receive less federal funding because of this.
• Most states going the partial expansion route are also trying to limit and discourage enrollment. A number have or are trying to implement work requires.
♦ Under the Biden Administration, CMS has withdrawn work requirement waivers for Arizona, Arkansas, Indiana, Michigan, New Hampshire, Ohio, South Carolina, Utah and Wisconsin.
Nebraska withdrew its request for a work related waiver.
Georgia was challenged by CMS and as a result has not been able to implement their work related waiver.
CMS under the Biden Administration has not yet acted on the pending work requirement waivers, but it is expected that these will be rejected.
Rejected by the courts:
- New Hampshire
A few states have been granted waivers that will restrict enrollment. Some have waivers which would allow changes to benefits and copays.
Where we are now
♦ Arkansas continues to operate its expansion program through a waiver. However, the waiver provisions related to work requirements and reduction of retroactive eligibility were set aside by a court on March 27, 2019.
In September 2021, Arkansas submitted a new Section 1115 waiver request to CMS. The new waiver does not include a work program but instead would allow the state's health plans to "incentivize" enrollees to health improvement and economic independence initiatives. People who do not take part in the "incentives" could be kicked off Medicaid.
♦ New Hampshire's work requirement waiver was set aside by the court on July 29, 2019. It was estimated that 17,000 people were going to lose coverage if the waiver had gone through.
♦ Wisconsin covers adults up to 100% FPL in Medicaid but did not adopt the ACA expansion.
In 2018, Stacy Abrams (D) ran for governor on a promise to expand Medicaid. Fearing she might win; the Republican controlled state house passed a resolution preventing any future governor from expanding Medicaid without their approval.
Ms. Abrams came extremely close to an upset win. She continues to insist she would have won if not for voter suppression overseen by her rival at the time, Brian Kemp.
♦ The election of 2018 should have been a wake-up call for Georgia Republicans. Unfortunately, they continue to bury their heads in the sand.
There is no plan for stabilizing rural hospitals. They continue to ignore the fact that 20.7% of Georgians ages 19 to 64 are uninsured, one of the worst rates in the nation.
• Early 2019, Governor Kemp announced he was open to a limited expansion of Medicaid.
The Kemp administration hired Deloitte, an outside firm, to craft a plan.
♦ November 2019, Governor Kemp presented a brief outline of his plan for partial Medicaid expansion up to 100% FPL. Under Governor Kemp's plan up to 50,000 people may be eligible.
In Georgia an estimated 408,000 people make less than the federal poverty level but do not qualify for Medicaid. Governor Kemp's grand plan appears to leave the major of these people out in the cold.
• Proponents of full Medicaid expansion were quick to ask, "What about the other 358,000 poor people?"
♦ December 23, 2019, the state submitted a waiver request to CMS. It does not appear to be serious.
The waiver is seeking enhanced funding match at the 90% level despite the fact that CMS has already indicated they will not approve such funding for a partial expansion. Georgia's waiver request also includes work requirements, premiums and copays.
• The Trump administration recently rejected a conservative proposal for Utah with limits similar to what the Kemp administration is suggesting.
The Kemp administration is requesting a waiver of the requirement to provide three months retroactive coverage.
They are also seeking to waive hospital presumptive eligibility. This is a policy option that allows hospitals to provide temporary Medicaid coverage to individuals likely to qualify for Medicaid. The Kemp administrations would like people to wait until an application is approved.
• In 2018, Georgia Republicans pushed through a tax cut which along with the pandemic caused a shortfall in the budget.
• In 2022, Georgie Republicans boasted that the budget had a surplus but they would not consider funding Medicaid expansion. To help bolster fall elections they gave teachers a small raise and once again pushed through a tax cut that mostly benefits upper-income Georgians.
There is very little talk of Medicaid expansion since the Biden administration nixed Governor Kemp's plans in 2021.
► Governor Kemp’s proposal consists of a second part which is very controversial. Governor Kemp is requesting that the state take control of federal subsidies that the ACA exchange currently provides to Georgians.
Under the Kemp plan, Georgians would lose access to the federal exchange. The state would take the subsidy money and spread it around. The Kemp plan calls for using this money for plans that are not eligible now – skimpy, short-term and employer sponsored insurance.
• Opponents point out, the pie is only so large, the more you slice it the less there will be for people currently receiving coverage through the exchanges.
These waiver requests were not expected to be approved but then on October 15, 2020 CMS gave approval for a Section 1115 waiver. This was quickly followed on November 1st with approval for a Section 1332 waiver to allow Governor Kemp to take money intended for the exchanges and shuffle it to insurance companies.
• In an unusual move the Trump administration tacked on a provision to allow Georgia to seek financial compensation in the event that their plans are stopped by the next administration. It seems someone had serious concerns about the outcome of the presidential election.
There will certainly be legal challenges. Most legal experts do not expect these waivers will stand up in court. The Biden administration will likely rescind them.
♦ In February 2021, the Biden administration put Georgia's Medicaid expansion plans on hold by signally their intention to withdraw approval for waivers for work requirements.
• Late July, CMS gave Georgia until August 29th to recalculate some of their numbers they presented to support their waiver to shutdown the Affordable Care Act's federal health insurance shopping website.
Critics of the ACA shutdown waiver say that Governor Kemp and his aides cannot come up with the numbers to justify their plans since the first go around under the Trump administration used cherry picked data and then some creative cooking.
Governor Kemp has threatened to sue if his doesn't get his waivers.
♦ December 23, 2021, Georgia's Medicaid waiver was denied.
♦ August 2022, a Federal District Court judge vacated CMS's rescission, thus reinstating Georgia's waiver. CMS may appeal the decision. The waiver if it holds up would not qualify for enhanced matching funds.
Georgia's cost per enrollee for their Medicaid plan is expected to be three times higher than it would have been under regular Medicaid expansion.
♦ The Biden administration allowed the 60-day appeal window to lapse without doing anything. Georgia's Medicaid waiver may now proceed. It will require 80 hours of work or volunteering a month.
Georgia's plan will probably not start until the end of the COVID-19 public health emergency, which provides coverage for many Medicaid enrollees during the pandemic. The emergency declaration will likely be extended into early next year.
♦ April 29, 2022, the Biden administration blocked Governor Kemp's plans to shut down the Affordable Care Act's website. This means Governor Kemp's plan to redirect federal funds to individual insurance companies and brokers is not going to fly.
Governor Kemp had until July 28th to come up with a new improved scheme that will show less people losing their coverage.
On July 27th the Kemp administration responded to the earlier denial. The did not have an updated plan to present to meet CMS guidelines. Their response was to complain that CMS did not have the authority to challenge their plan, which CMS immediately shot down.
The Georgia Access Model was officially killed on August 9, 2022. However, CMS indicated they would remain open to reviewing a new plan if the Kemp administration could come up with one.
• Congress later passed the American Rescue Plan (ARP) which extends enhanced Premium Tax Credits through 2025.
This will lead to more people signing up for health insurance through HeatlhCare.gov. As result, the Kemp administration will have an even harder time cooking the numbers to get the Georgia Access Model to fly.
Georgian’s will continue to wait.
Idaho voters approved a ballot measure in November 2018 to implement Medicaid expansion. The state had 90 days to submit a plan to CMS. Idaho submitted a plan in February 2019.
♦ On April 9, 2019, Idaho Governor Brad Little (R) signed a bill passed by the legislature to try to make changes to the Medicaid expansion program approved by voters.
The Governor is asking for a waiver to allow a work requirement as a condition of eligibility for coverage.
The state would provide coverage to individuals earning up to 100% of FPL instead of up to 138% if this is approved. This would be a partial expansion.
It is estimated that this scheme will cost the state millions in federal dollars.
♦ The legislation specifies that if the waivers are not approved by January 1, 2020, then all individuals up to 138% of FPL will be enrolled in Medicaid. Idaho would then be eligible to receive 90% funding from the federal government.
Idaho was not able to get their waivers to fly. On January 1, 2020, Medicaid expansion up to 138% FPL went into effect.
• In 2022, Idaho had to increase funding for Medicaid by 6.6% to cover costs. This action cause a ruckus among a number of conservatives.
Kentucky originally implemented a traditional Medicaid expansion in January 2014.
Kentucky's uninsured rated dropped from 20% to 8%.
♦ Republican Matt Bevin was elected governor in December 2015. He ran on a platform to end the Medicaid expansion and to also shut down the state-based Marketplace.
• Kentucky shuttered the state health insurance exchanges. 2017 Obamacare enrollment switched to HealthCare.gov.
Governor Bevin learned he had to give up on his quest to end the expansion. Instead he decided to change the state’s traditional Medicaid expansion into something more palatable to his Republican colleagues. To do this he needed to request a waiver from CMS.
♦ Work requirements would have been one thing but the Bevin administration is trying to push the envelope a bit too much. So, the courts keep telling them.
• On March 27, 2019, the court struck down the latest waiver that CMS approved for the state. This is the second time the courts have rejected Kentucky’s waiver after CMS had given their approval.
♦ Kentucky is trying to introduce a work requirement along with a number of other controversial changes.
The Bevin administration wants to raise monthly premiums up to 4% of income, lockout people when they fail to renew on time or fail to report changes in their circumstances. Actions advocates complain are designed to push people off of Medicaid.
Kentucky has also asked to increase cost-sharing to people who use an emergency room for non-emergency reasons. They also want to get rid of retroactive eligibility and non-emergency medical transportation.
♦ On December 16, 2019, Democratic Attorney General Andy Beshear defeated Bevin in the gubernatorial race. On December 16th, Beshear signed an executive order rescinding Kentucky's health waiver.
The people of Maine have had a hard fight but it looks they are finally going to get their wish.
♦ In 2017, the voters of Maine approved a referendum calling for the expansion of Medicaid. Governor Paul LePage (R), a strong opponent of Medicaid expansion, refused to go along.
The referendum required the LePage administration to submit a plan to CMS by April 3, 2018 and to start enrollment by July 2, 2018.
• Governor Paul LePage refused to expand Medicaid, saying the legislature had to first come up with adequate funding. Governor LePage also stipulated that he would not allow the raising of taxes or the use of the state’s rainy-day fund. Although he did say he would agree to the taxing of hospitals.
♦ Governor LePage vetoed five funding bills passed by the legislature to get the expansion moving.
In the end, the governor had to be sued to force him to submit a plan. The judge overseeing the case chastised the administration for their delay tactics. The LePage administration filed an appeal but they did submit a plan.
• June 2018, Governor LePage finally submitted a plan to CMS. It was not entirely what the voters of Maine had thought they would be getting. Governor LePage submitted a plan but then followed this up with a letter to the Trump administration asking them to not approve Maine’s plan.
The LePage administration then submitted a request for a waiver to include a work requirement.
• In December, the LePage administration’s appeal was argued. The judge rejected the LePage administration’s arguments and ordered them to implement the Medicaid expansion. An extension was granted until February 1, 2019 but with retroactive coverage for people who applied since July of 2018.
Governor LePage could not run for re-election in 2018. Democrat Janet Mills, who served as Maine’s Attorney General, won the race in part on her support for Medicaid expansion.
♦ January 2019, Governor Janet Mills signed an executive order on her second day in office that directed the state to pick up the pace and expand Medicaid.
Governor Mills also make coverage retroactive to people who would have been covered starting as early as July 2, 2018, if the LePage administration had not hindered the expansion.
April 2019, CMS approved Maine’s application to expand Medicaid. The federal government paid 93% of expansion costs in 2019 but that dropped to 90% in 2020.
The new Democratic led Maine legislature approved legislation to finance the state's share of the expansion cost, which will total 10% starting in 2020 and thereafter.
• In December, CMS approved the LePage administration's request for a Medicaid waiver requiring traditional Medicaid beneficiaries to participate in work activities to receive benefits.
Soon after taking office, Governor Mills notified CMS that her administration would not accept the waiver.
Missouri voters approved a ballot measure on August 4, 2020 which adds Medicaid expansion to the state’s constitution.
The amendment requires the state to submit to CMS a plan to implement expansion no later than March 1, 2021.
Expansion coverage is to begin July 1, 2021. Coverage will be available to adults with incomes up to 138% of FPL.
Language in the amendment prohibits the imposition of any additional burdens or restrictions on eligibility or enrollment for the expansion population.
GOP lawmakers in the state might still try to throw a monkey wrench in by trying to craft their own version of Medicaid expansion. But time running out to get this done.
May 13, 2021, Governor Mike Parson announced that the Department of Social Services (DSS) was withdrawing its state plan and would not implement expansion on schedule due to lack of funding.
May 20, 2021, advocates filed a lawsuit against the DSS.
June 23, 2021, a circuit judge (Republican) ruled in favor of the DSS.
July 21, 2021, the Missouri Supreme Court ruled against the governor and ordered the state to proceed. Missouri began implementing the expansion by accepting applications on August 10, 2021 with coverage to be retroactive to July 1, 2021.
The legislature is controlled by Republicans who really do not want to obey their voters on this one.
In February 2022, they tried to introduce a constitutional amendment that would impose work requirements and also give the legislature power to play around with Medicaid appropriations every year. The legislature adjourned before these tricks could be rammed through. There is always next year.
Montana voters voted down a measure on the November 2018 ballot that would have extended the Medicaid expansion beyond June 30, 2019.
The referendum that failed would have raised taxes on tobacco products to finance the expansion.
♦ Montana’s Medicaid expansion rests in the hands of a moderately red legislature.
• On April 18, 2019, the legislature passed a bill to continue the state’s expansion program until 2025 but with significant changes.
The state submitted a Section 1115 waiver proposal to CMS on August 30, 2019.
The waiver requests permission to add a work requirement as a condition of eligibility and increase the premiums.
Nebraska voters approved a Medicaid expansion ballot measure in November 2018 and the state submitted a plan to CMS on April 1, 2019.
♦ The plan delays Medicaid expansion implementation until October 1, 2020 to allow time for the state to seek a Section 1115 waiver.
An estimated 94,000 low-income Nebraskans will have to continue to wait to get the Medicaid coverage approved by voters over one year ago. And it won’t be what the voters approved.
♦ On December 12, 2019, the state submitted a waiver to CMS. The waiver asks permission to implement work requirements and other community rated services.
Those newly eligible Nebraskans will have different benefits and requirements than others on Medicaid. To get full coverage, they would have to work, care for a family member, volunteer, look for work, or attend college or an apprenticeship.
♦ A waiver will also be used to ask CMS to allow Nebraska to split their Medicaid expansion into a two-tier system.
There would be two levels of coverage, basic and prime. Basic coverage would be a watered-down version rather than traditional Medicaid coverage. The prime level would include additional benefits such as dental, vision and over-the-counter medications. Things that are already part of traditional Medicaid coverage.
• Most people would start out with basic coverage. To move up to prime coverage, people would have to cooperate with care management activities offered by the contractors. They also would have to choose a primary care provider and attend an annual checkup.
• In their second year of coverage, people would have to meet “community engagement” requirements to get prime coverage. Those include caring for a family member or spending at least 80 hours a month volunteering for a public charity, attending a postsecondary school or apprenticeship, working or looking for work.
Kentucky and Arkansas tried to include community engagement requirements and they were blocked in federal court.
♦ On October 20, 2020, CMS approved Nebraska's waiver with implementation of some waiver elements to begin on April 1, 2021 and others (including the work requirement) to follow one year later.
February 2021, CMS withdrew Nebraska's approval for work requirements.
August 17, 2021 the state gave up and withdrew its waiver request. CMS approved the withdrawal on September 2, 2021.
Ohio’s former Governor John Kasich (R) found a way around the Republican controlled legislature and expanded their Medicaid program on Jan. 1, 2014. Ever since then, Republicans have been trying to put additional requirements on Medicaid beneficiaries.
• In 2016, a plan to have people pay into health savings accounts was rejected by CMS.
After Governor Kasich went around them, the legislature included language in a budget bill requiring the addition of a work requirement.
The Ohio Department of Medicaid was then required to request a waiver from CMS to add job requirements for those covered through Medicaid expansion.
♦ March 2019, CMS gave Ohio approval to impose work requirements for those covered by Medicaid expansion. It will not be implemented until January 2021.
All able-bodied individuals up to the age of 50 would now be required to work, attend class or train for a job to qualify for benefits.
Thousands of poor Ohioans are expected to lose coverage for failing to meet these new requirements.
This follows a similar path experienced in Arkansas when that state started a similar work related program in 2018. In Arkansas’ case close 18,000 people lost Medicaid coverage.
Ohio planned to implement work requirements at the start of 2021, but it was delayed due to the Covid pandemic.
During the pandemic Ohio is received additional federal Medicaid funding. That money came with strings attached.
The state could not impose new rules that would reduce eligibility or result in termination of coverage.
Ohio had to pause their work requirement plans. Had the work requirements gone into effect, Ohio estimated that more than 18,000 beneficiaries would have lost Medicaid coverage.
Oklahoma submitted an expansion plan to CMS on May 28, 2020. The plan was asking for a waiver to change the financing structure of the program and impose premiums and work requirements on enrollees.
♦ On June 30, 2020, voters approved a ballot measure which adds Medicaid expansion to the state’s Constitution. The amendment requires the Oklahoma Health Care Authority to submit a plan to CMS within 90 days of the ballot measure’s approval.
Expansion coverage to begin no later than July 1, 2021 for adults with incomes up to 133% of FPL.
♦ July 1, 2021, CMS announced that approximately 190,000 individuals between the ages of 19-64 are now eligible for health coverage, thanks to Medicaid expansion.
November 8, 2022 - South Dakota voters approved a constitutional amendment to expand Medicaid.
The amendment requires South Dakota to implement expansion coverage beginning July 1, 2023.
Republicans control the state so some meddling is expected before the dust has settled.
Utah voters passed a ballot measure in November 2018 that required the state to expand Medicaid coverage to 138% of FPL beginning April 1, 2019. The voters also approved a 0.15% increase in the state sales tax to finance the expansion.
♦ The Governor and his supporters in the legislature had other plans. On February 11, 2019, Governor Gary Herbert (R) signed legislation that made significant changes to the version of expansion that voters approved.
The Governor requested a waiver to add a work requirement as a condition of eligibility and changed expansion to cover up to 100% of FPL rather than 138% of FPL as the voters approved. The Governor also asked to cap enrollment and to incorporate a per capita cap on federal reimbursement.
• CMS approved a demonstration waiver in Utah for adults with incomes up to 100% of FPL beginning on April 1, 2019 but using the state’s regular Medicaid match rate, not the enhanced ACA match rate.
The state was given the authority to close enrollment for this group if projected costs exceed state appropriations. Non-exempt individuals in this group will be subject to a work requirement, which is set to begin no sooner than January 2020.
• The state submitted another waiver amendment to CMS that requests additional program changes, including authority to use the ACA enhanced match rate for the partial expansion population up to 100% of FPL as well as a per capita cap.
CMS issued a statement saying that state requests to cover only a portion of the adult expansion group and still access enhanced federal funding would not be approved. This means that Utah can receive 60% funding instead of 93% in 2019.
• According to the Governor’s statement, the state now intends to provide coverage to 138% of FPL with the ACA enhanced match and seek waiver authority to implement a number of provisions including an enrollment cap, a per capita cap on federal reimbursement, and a work requirement.
If this waiver is not approved another waiver will be submitted which would remove provisions like the federal per capita cap but keeps the enrollment cap and work requirement.
December 23, 2019, CMS approved Utah's waiver request to include work requirements but did not approve the request to cap enrollment.
♦ Medicaid expansion up to 138% of FPL became effective on January 1, 2020.
In August 2021, the Biden administration withdraw waivers with work requirements.
Republican lawmakers in the state had blocked Medicaid expansion for four straight years, but a number of them dropped their opposition after their party almost lost the House of Delegates in 2017. And after Democratic governor Ralph Northam agreed to include a work requirement.
♦ Medicaid expansion began January 1, 2019. Coverage is provided to people earning up to 138% of FPL.
Virginia submitted a waiver request to CMS in November 2018. Apart from the work requirement, the waiver would allow Virginia to make certain enrollees pay premiums and copayments “to encourage personal responsibility” and prepare them for having private or employer-sponsored insurance.
♦ There has been a lot of back and forth negotiations with CMS. As a result, the waiver request is still pending.
• It would reward people who are healthy and regularly pay their premiums by lowering the cost of those premiums and copays. The waiver would also provide housing and employment support for high-risk adults who have a mental illness, a substance abuse disorder or a complex chronic illness.
♦ In early December 2019, a few weeks after the Democrats won control of both the House and Senate, CMS was informed that Virginia would be delaying further negotiations. This signals the end of the push for work requirements.
Wisconsin is the only state that partially expanded Medicaid, to include all adults under 100% of FPL. Those with incomes over 100% of FPL are eligible for subsidized insurance through the Exchange.
Because of this partial expansion Wisconsin can avoid the “coverage gap” experienced by states like Georgia where the income of some people falls below 100% of FPL and they cannot get a Marketplace subsidy but are considered too rich for Medicaid. They get no help. Wisconsin does not have this problem.
♦ Republican Scott Walker lost the governor’s election in 2018 to Anthony Evers, referred to as Tony Evers.
Governor Tony Evers (D) has proposed expanding Medicaid eligibility up to 138% of FPL. This would cover an additional 82,000 residents.
♦ June 2019, Wisconsin’s Republican controlled budget committee voted to reject Governor Evers' plan to expand Medicaid. It was a partisan decision. One that will cost the state more than $1 billion in federal funding and $324 million in savings.
• Republican Senator Alberta Darling said the committee was investing in people, not programs. "We're not expanding welfare, that was the big concern," she said.
A common theme of the GOP.
♦ Public opinion polls showing support for expanding Medicaid is as high as 70%.
On May 25, 2021, Governor Evers called for a special session to present Medicaid expansion legislation.
Governor Evers wanted to take advantage of additional federal funds provided by the American Rescue Plan Act.
The Republican-controlled legislature adjourned rather than discuss the legislation.