in Health­care

Modern Healthcare - - THE WEEK IN HEALTHCARE -

to con­sider this week whether to back a Med­i­caid ex­pan­sion in that state, said Bruce Rueben, pres­i­dent of the Florida Hospi­tal As­so­ci­a­tion.

“Cer­tainly, we are talk­ing to the busi­ness com­mu­nity about why it is in the best in­ter­ests of Florida’s busi­ness com­mu­nity to sup­port the ex­pan­sion of cov­er­age,” Rueben said. “Ob­vi­ously, the busi­ness com­mu­nity has strong sup­port from Florida’s Leg­is­la­ture.”

Sim­i­lar ef­forts are un­der way in Texas and Ohio, two other large Repub­li­can-led states seen as Med­i­caid bell­wethers. Med­i­caid ad­vo­cates in both states have been cel­e­brat­ing re­cent pub­lic en­dorse­ments from lo­cal Cham­bers of Com­merce, but so far have failed to gar­ner sup­port from their statewide busi­ness groups.

But pol­icy ex­perts cau­tion that even when broad coali­tions have suc­ceeded in con­vinc­ing gov­er­nors to pur­sue an ex­pan­sion, an ex­ten­sive amount of ad­vo­cacy work re­mains.

“That’s just the gov­er­nor—you’re still go­ing to need to get the leg­is­la­ture to do this,” said Matt Salo, ex­ec­u­tive di­rec­tor of the Na­tional As­so­ci­a­tion of Med­i­caid Direc­tors.

Sup­port­ers of the ex­pan­sion also are mak­ing in­roads by show­ing law­mak­ers where to find the money.

Med­i­caid ad­vo­cates em­pha­size that the fed­eral government would cover most of the

tab—in­clud­ing 100% of the cost of newly el­i­gi­ble en­rollees for the first three years— although pol­icy ex­perts have iden­ti­fied ad­di­tional costs states will in­cur.

For ex­am­ple, a Novem­ber 2012 anal­y­sis by the Kaiser Com­mis­sion on Med­i­caid and the Unin­sured con­cluded that if all states un­der­took the ex­pan­sion, it would cost them a to­tal of $76 bil­lion from 2013 to 2022. It could be less, the com­mis­sion noted, be­cause of off­set­ting re­duc­tions in spend­ing in other ar­eas, in­creased tax rev­enue or other fac­tors.

“We’re not say­ing you won’t have to put more money in your Med­i­caid bud­get,” said Kath­leen Stoll, di­rec­tor of health at Fam­i­lies USA, a lib­eral pa­tient ad­vo­cacy group based in Washington.

State fis­cal of­fi­cers, who can­not in­clude hoped-for sav­ings in their bud­get blue­prints, have be­gun search­ing for ways to cover the cer­tain ex­penses the state will face in the next fis­cal year.

Med­i­caid ad­vo­cates have tried to help find those “pay­fors.” For ex­am­ple, they have sug­gested a range of new taxes to cover the state share, in­clud­ing cig­a­rette, al­co­hol and lux­ury taxes. Two other ex­pan­sion ideas that could im­pact hos­pi­tals are cuts in state sub­si­dies for un­com­pen­sated care and in­creased provider taxes.

Hos­pi­tals in Ari­zona backed Brewer’s pro­posal for a new provider as­sess­ment that would col­lect $154 mil­lion, or the en­tire firstyear state share of the cost of ex­pan­sion.

How­ever, the long-term vi­a­bil­ity of provider taxes as a fund­ing stream is “defi- nitely a con­cern,” said Wertheim, of the state hospi­tal group, be­cause the Obama ad­min­is­tra­tion and Congress have re­peat­edly pro­posed slash­ing or elim­i­nat­ing such taxes, which draw ad­di­tional fed­eral match­ing funds. Many fed­eral of­fi­cials have crit­i­cized the taxes as a “scam.”

Mean­while, the CMS re­cently in­tro­duced the op­tion of off­set­ting Med­i­caid costs with higher cost-shar­ing for some ben­e­fi­cia­ries. That flex­i­bil­ity was tucked into a se­ries of pro­posed Af­ford­able Care Act reg­u­la­tions is­sued Jan. 14.

“We’ve heard a lot of gov­er­nors say, ‘We want this to look like pri­vate cov­er­age, we want peo­ple to con­trib­ute,’” said Judy Solomon, vice pres­i­dent for health pol­icy at the lib­eral Cen­ter on Bud­get and Pol­icy Pri­or­i­ties. “So the reg­u­la­tion ba­si­cally says, ‘Here it is, here’s how you can do that.’”

But crit­ics dis­missed the op­tion as un­re­li­able. Dur­ing the bud­get fights over the past year, Pres­i­dent Barack Obama has pro­posed cut­ting the amount of the fed­eral Med­i­caid fund­ing match, which some see as ev­i­dence that the fed­eral government could trim its com­mit­ment at any moment.

“Th­ese are pretty trans­par­ent and tem­po­rary ef­forts to in­duce states to bail out the fed­eral government and do the heavy lift­ing that the fed­eral government wants them to do,” said Michael Can­non, di­rec­tor of health pol­icy stud­ies at the lib­er­tar­ian CATO In­sti­tute. “There is noth­ing per­ma­nent about th­ese of­fers of flex­i­bil­ity be­cause(the) fed­eral government could re­voke them all to­mor­row, es­pe­cially when they are done ad­min­is­tra­tively in­stead of through statute.”

Dr. Brent Sher­ard, left, spokesman for the Wy­oming In­te­grated Care Net­work, speaks Jan. 22 in fa­vor of ex­pand­ing the fed­eral Med­i­caid sys­tem.

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