Political, legal battles continue over Medicaid expansion

The ideological battle over the Affordable Care Act’s Medicaid expansion continued to run hot in 2019, with state GOP officials pushing to impose restrictions on coverage even in states where voters mandated it.

Republican officials in Idaho, Nebraska and Utah delayed full implementation of voter-approved Medicaid expansion and sought to impose work requirements and other restrictions on eligibility.

But a federal judge threw out the Medicaid work requirement waivers in three other states, saying the CMS didn’t adequately consider the effect on coverage. A federal appellate court ruling is pending. The lesson of Arkansas, where 18,000 people lost coverage in 2018 under a work requirement rule, loomed large in the legal and political arguments.

On the other hand, at least three more states considered expanding Medicaid to low-income adults. Republican lawmakers in North Carolina stymied Democratic Gov. Roy Cooper’s expansion push but say they’re open to considering it next year. Oklahoma supporters gathered enough signatures to place expansion on the ballot next November. Georgia Republican Gov. Brian Kemp proposed a partial expansion covering those at up to 100% of the federal poverty level, even though the CMS rejected Utah’s similar proposal in July.

Beyond that, the Trump administration and GOP leaders in Tennessee and Utah are considering plans to shift Medicaid from an openended entitlement program to a capped federal funding model. Healthcare leaders fear cuts under this structure, though some say it could boost funding at least in the short term.

Lawmakers and regulators talked big on tackling high drug prices and surprise medical bills in 2019, but agreement on bipartisan policies remained elusive. Some legislation could be attached to a potential budget deal in December, but it is still unclear whether lawmakers will resolve funding disputes by year-end.

Intense lobbying efforts from several industries played a big role in stalling progress. Drugmakers are fighting a provision in the Senate Finance Committee’s drug-pricing bill that would require them to pay back Medicare if prices outpace inflation, and providers and insurers are warring over how to handle out-of-network bills. A drug-pricing bill passed by House Democrats last week won’t see action in the GOP-controlled Senate.

The administration could at any time release a regulation outlining a process to allow states to import prescription drugs from Canada or move forward with a demonstration that would tie payments for physician-administered drugs in Medicare to international drug prices.

Rival approaches to address surprise medical billing came to a head in December when a bipartisan, bicameral compromise proposal emerged (See story, p. 8), but a key Senate Democrat involved in the negotiations had not signed on as of deadline. Provider groups still oppose the legislation and it’s unclear whether House and Senate leadership have an appetite to include it in must-pass budget legislation.