Medicaid Expansion gets entrenched in Arkansas -- even with a conservative GOP government

The latest news out of Arkansas offers more evidence that the Medicaid expansion will durable even in the most conservative states once it gets entrenched.  

I argued this point tentatively in March when new Republican Governor Asa Hutchinson and large GOP majorities in the state legislature reauthorized the expansion, which had been put in place under Democrat Mike Beebe’s administration, for the current fiscal year while putting together a task force to examine long-term tweaks in the system.

Arkansas has an unusual expansion: instead of simply enrolling everyone eligible in traditional Medicaid, the expansion provides subsidies to fully pay for private health insurance sold on the exchanges. As Richard Mayhew notes, commercial policies have higher costs than Medicaid, so the plan is a more expensive piece of “performance art,” albeit one that still accomplishes the primary goal of getting people covered.

The Arkansas Times picks up the story from there. As the federal match starts dropping in 2017 (and Arkansas enters new negotiations for a waiver with the Feds), the state found its was going to be on the hook for an extra $50-60 million, and Hutchinson implored the task force to cut costs.

Last week he met with the Task Force and made a speech with three major parts.

First, he engaged in the usual right-wing Kabuki ritual of complaining about how horrible Obamacare was and that it was taking away health insurance and….

(insert Charlie Brown trombone sounds here).

Oh, sorry, nodded off there. 

Second, he offered several of the usual conservative pet rocks to cut costs: notably requiring  more premium cost sharing for people above the poverty line (Iowa does this and the Feds would likely approve it in a waiver), requiring some sort of job search requirement for people on Medicaid that wouldn’t require a new waiver (this Feds won’t tolerate much here, and most of the people on expanded Medicaid work anyway) and making sure that working people with access to health insurance take that rather than enrolling in Medicaid (this will affect almost no one).

Finally, after emphasizing his anti-Obama bona-fides, he got to the real point: The Medicaid expansion had covered more than 220,000 of “our friends, our neighbors and our families,” and that rejecting it would cut them off of health care and drain more than $1.4 billion from the state economy. He also made the biggest policy proposal, which would be to shift everyone below the poverty line from private plans to the cheaper (and just as comprehensive) traditional Medicaid.

So the big conservative plan to tweak the “private option” Medicaid expansion in Arkansas and be fiscally responsible is to …. move more people into traditional Medicaid, just like Obamacare originally envisioned. I swear HHS Secretary Sylvia Burwell and President Obama just exchanged knowing glances and an extremely restrained fist bump in the Oval Office.

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ACA reduces uninsured in Texas, but would do more if state expanded Medicaid

Shockingly (not really), failure to expand Medicaid continues to cost poor Texans access to health insurance.

The Baker Institute at Rice University the Episcopal Health Foundation have released their latest issue brief on the latest results of the Health Reform Monitoring Survey, a quarterly survey which tracks the effects of the Affordable Care Act on individuals.  The Institute and  the Foundation implement the survey for Texas.

This report contains absolutely no surprises for anyone with more than three functioning brain cells and who hasn’t been living under a rock for the last five years.

First, the good news: The percentage of uninsured working-age adults (ages 18-64) estimated by the survey declined by nearly one third, from nearly 25 percent to 17 percent between September 2013 and March 2015. Most encouragingly, Hispanics – though still the higher proportion of uninsured in Texas – had the largest decline, with a drop of 38 percent.

This indicates that the health exchange model, supported by federal subsidies, is helping a large number of uninsured individuals get coverage.

The bad news of course, is that poor people who fall into “Medicaid gap” – those who earn income less than 100 percent of the poverty line necessary to obtain subsidies on the exchange, but higher than current Texas cutoffs for Medicaid -- are still left out in the cold.  The memo notes that respondents under 138 percent of the poverty line have increased from roughly 63 percent to 67 percent of those uninsured in Texas. This change in the two surveys isn’t statistically distinct from zero, but almost surely understates the impact of the state’s failure to expand Medicaid, because individuals between 100-138 percent of the poverty line qualify for subsidies.

Two other nuggets in the report are of interest.  First, the potential tax penalty for health insurance, also known as the individual mandate -- appears to have some effect on driving the uninsured to seek insurance. More than half (53 percent) of uninsured respondents say that the prospect of a fine for not purchasing insurance is “somewhat” or “very” important to them. (Note that the IRS is waiving the fine for households that fall into the “Medicaid gap.”

Finally, uninsured respondents overwhelming say that they can’t purchase insurance because they can’t afford it (57 percent) instead of because they don’t want it (17 percent). That’s useful because it undermines (again) the talking point that uninsured people are satisfied in their current state and that the government should just butt out.

To sum up then: Texans generally want health insurance, the ACA is effective in helping them get insurance, and the ACA would help a lot more Texans get insurance if the state were to expand Medicaid. Absolutely all these things were predicted by proponents of Obamacare.

Montana on cusp of passing Medicaid expansion

In breaking news yesterday, the Montana House of Representatives passed a Medicaid Expansion Bill to a final reading by a 54-46 vote.

The expansion called the Health and Economic Livelihood Partnership Act (HELP Act), is a slightly  amended version of Senate Bill 405, which was approved in that chamber on March 30 by a 28-21 vote. The amended House version, slated for final approval today is almost certain to pass the Senate next week, after which Democratic Governor Steve Bullock will be extremely likely to sign the HELP Act into law.

The bill is slightly different from a traditional Medicaid expansion in that it will require some beneficiaries to pay co-pays; and has a job search component. However, as Section 6 of the bill notes, those co-pays will not exceed caps and regulations established by law.  The job-search component (Section 14) also appears to not affect eligibility for expanded Medicaid and only asks the state labor and industry department to partner with the state health department to match up HELP beneficiaries with potential job openings.

This should get through the Federal Department of Health and Human Services with few problems.

In both chambers, a moderate Republican sponsored the bill. In the House, Democrats managed to get the bill out of a hostile committee that had bottled up both it and Bullock's own expansion proposal this year by using a legislative stratagem called the "Silver Bullet": Under a gentleman's agreement during this session that each party gets to move six bills of their choice that have been blocked in committee on to the House floor for a straight-majority vote. Eleven Republicans helped the 41 Democrats in the chamber get the bill on the floor, while 13 GOPers joined the Democrats to advance the bill to final passage.

There are four things about this that are great news:

1. Poor Democratic Representative Tom Jacobson will finally get to forget about his accidental vote that killed expansion in 2013.
2. These guys spent a lot of money on an astroturf campaign that is going to fail.
3. 29 states now will have expanded Medicaid coverage.
4. Best of all, 27,000 to 45,000 people are going to get access to health insurance.

Obama judicial appointments slow to a crawl

Much of the focus in the Senate right now is justifiably on the GOP majority's slow-walking Loretta Lynch's confirmation vote for attorney general on the Senate floor. 

But what's getting a lot less attention is the predictable lack of traction that President Obama's judicial nominations are getting.

The Senate has not confirmed a single judicial appointment this year in three months of work.

Contrast that with the first three months of 2014, the Democratic majority confirmed three circuit court judges and 16 district court judges.

In the first three months  of 2007, the incoming Democratic majority confirmed two of George Bush's circuit court nominees and 13 district court nominees.

Four rather uncontroversial district court nominations are waiting for a floor vote --three in Texas and one in Utah -- all which easily cleared the Judiciary committee in February. They'll get through the Senate eventually, but somehow I don't think Mitch McConnell has them as a priority.

Just another reminder that elections matter.

Obama moves a bit more on the environment

The New York Times reports that President Obama has signed an executive order that will seek to have all federal agencies reduce greenhouse gas emissions by 40 percent from their 2008 levels by 2025.

This isn't earth shattering in itself -- the federal government only accounts for 1 percent of U.S. greenhouse gas emissions. But it's not nothing either, as the government is the single largest purchaser of goods and services in the U.S.  It's policies can create markets for goods and service that can percolate through the rest of the economy, and its ability to bind federal contractors can help spread policies to a broader group of businesses.

The order extends a previous order signed in 2009 that required the government to cut emissions by 25 percent by 2020. The Feds are on track to meet it. Good on the administration for following up on earlier success.

Every ton of CO2 we keep out of the atmosphere helps. And this order will keep several million in the ground.

"Orthogonal to reality"

Jared Bernstein summarizes the 2016 House Republican budget about as pithily as possible.

Here's a look at President Obama's proposal.
The New York Times compares the GOP and Obama budgets. Note that they accept the assumptions implicit in both documents. For how strong those assumptions are, see Bernstein's comments -- the GOP budget is full of magical thinking and assumptions about how their tax cuts will magically transform into lower deficits.

And finally, here's an outline of the Congressional Progressive Caucus' "People's budget", which won't go anywhere because it's not Very Serious or something.

Oregon's new motor-voter law drastically eases registration, but still leaves a few blind spots

Newly minted Oregon Governor Kate Brown kicked her administration off with a bang on March 16, signing a motor-voter bill on steroids into law.

The law is good policy and will remove some considerable hurdles to voting for a large number of people. However, it does leave out potential voters and may not in itself increase voter turnout all that much.

The bill makes voting registration automatic for any eligible potential voter existing in the Oregon State Department of Motor Vehicles database. This feature goes far beyond current federal requirements, which only make it mandatory to allow an eligible resident to register to vote while obtaining a driver's license or conducting business at a state DMV. According to Reuters, the bill could expand registration by 300,000 voters – an increase of about 13.7 percent over the most recent voter roll.  

That’s good news and brings Oregon’s policies much more in line with most other industrialized democracies, which automatically register voters whenever they move. Coincidentally, most of those countries traditionally have had higher turnout than the United States. Better yet is that these policies will automatically keep track of people who tend to move around a lot and who have their registration fall through the cracks, like younger people – particularly students – and working families.

But the law doesn’t cover everyone. People without driver’s licenses (who often will not be in the DMV’s files) likely won’t be automatically registered; and those individuals tend to be disproportionately poor and people of color as we know from the battles over voter ID in numerous states.

Additionally, political science strongly suggests that easing barriers to voter registration doesn’t necessarily increase voter turnout. Candidates and parties still have to give people a reason to vote and activelywork to effectively mobilize and get them to the polls.[5]

So raise two-and-a-half cheers for Oregon making it easier to participate in the democratic process.  Now progressives just have to make it worth the new voters’ time to actually, you know, vote.