February 26, 2014
As originally published in the New Hampshire Union Leader
Some supporters of the Senate Medicaid Expansion Plan would have you believe the only two choices are their non-compromise and just saying no. As is typical, the reality is far more complicated. Most conservative opponents of the Senate’s Medicaid Expansion are more than willing to support a real compromise and have a more detailed knowledge of the plan and therefore its flaws than the public statements of some sponsors indicate they do.
A more detailed knowledge of the program suggests how and where compromise really is possible. The most obvious place is in the area of waivers. Senate Medicaid Expansion is best thought of as adopting the same program the governor proposed for a two year bridge period with the hope of changing it but only if the federal government grants us permission.
Sponsors of the program have claimed they can’t support the governor’s proposed expansion but can support the program the federal government may or may not approve.
Most conservatives believe that starting a program before the waiver is approved eliminates any real negotiating power with the federal government and then locks us into a program that will always be reauthorized because of irresistible political pressure. No significant social benefit program can be reversed.
Supporters are confident their program will be approved. But remember that we are asking the federal government to pay New Hampshire 100% of the costs of our program or the program won’t continue after December 2016 (see section XXV-c). In 49 other states the feds will only pay 90% so to continue the program we would be asking the feds to do something they can’t do. I’m all in favor of asking for anything but the feds have already turned down this request and can not realistically ever approve such disparate treatment.
Knowing that, we know with as much certainty as we can in a situation like this that the waiver will not be approved, at least not beyond the first year. So we are adopting the governor’s preferred expansion with no real concessions to conservatives about who is covered, the total size of Medicaid in the state, or how the benefits are administered.
In two years, the legislature will be asked to reauthorize a program that is providing health benefits to between 50 and 80,000 people. We will be told they tried to do something better and couldn’t but now we have no choice.
Why would it not be better to ask for all waivers up front? The plan is essentially a replication of Iowa’s. Iowa did not expand until the waiver was received. If the federal government had rejected any important component, Iowa would not have proceeded. That is clearly a stronger negotiating position that adopting something the federal government prefers and then hoping they’ll give us permission to make changes they and that are not being detailed.
Time is not that big an issue here. Iowa’s waiver took seven months from the bill’s passage even though they had to write a waiver from scratch with no examples to follow and the federal government had to rule on something they hadn’t seen before. In our case, we’re merely piggy-backing and the feds have seen every component of what we want before. Further, it is a poorly kept secret that the administration has been having informal conversations with the feds for months.
The second obvious area of compromise is in enrollment numbers. At this point, virtually everyone agrees that there ought to be a safety net. Most of us are willing to see Medicaid changed into a program with income based targeting of the benefit instead of categorical targeting. But the Senate Medicaid Expansion will increase the number of our citizens under Medicaid-funded social welfare programs from 135,000 to, by my estimate, 217,000 – an increase in the program’s size of more than half.
Would it not be reasonable to target the resources to the poorest 135,000 people? The governor showed us the way with her treatment of the breast cancer eligibility. Everyone in that program over 138% of federal poverty would receive the sliding scale subsidy offered by the exchange while those below would remain Medicaid eligible. If this same principle were applied to other populations it would alleviate much of the conservative concern about an enormous expansion of a dependency culture.
Almost no conservative of any variety would have any quibble with a decision to cover the same number of people but target that coverage to the lowest income levels.
A real compromise is still possible and desirable. But it has to acknowledge at the start that the current proposals is mistaken in not asking for waivers up front, in not endorsing any cost sharing measures, and in not redirecting resources instead of just expanding. While any conservative could support real compromise, no conservative of any shade or stripe can embrace the lack of compromise called Senate Medicaid Expansion.