Democrats plot backdoor of Medicaid expansion in Red States rejecting program

Expanding coverage to the roughly 2.2 million people without affordable health insurance options in states blocked by the expansion of Medicaid would fulfill a campaign pledge from Biden while his other key healthcare promises, like government drug price negotiations and a public option, face tough challenges in Congress. Democrats also believe it would provide a major victory for their party ahead of the hotly contested midterm elections next year, given that the Medicaid expansion has worked well, including in states where Republican leaders have been working well. have stuck for years.

However, the new effort carries risks that Democratic lawmakers, White House officials and healthcare advocates have struggled to resolve in behind-the-scenes discussions in recent months, people involved in the talks say. . One of the challenges is to design a program that won’t invite backlash from a healthcare industry ready to fight Democrats over other sweeping changes. Another concern is inadvertently rewarding states that have blocked the expansion of Medicaid for years. Any plan would also come with a hefty price tag.

“It is fairly universally recognized that action is needed to reach out to the people,” said Henry Connelly, spokesperson for House Speaker Nancy Pelosi. “Everyone is exploring ways to do this.”

Democratic lawmakers are weighing a few options that could potentially fit into a major economic package they hope to push through this year along party lines. But they have yet to agree on an approach, and Democratic leaders face competing demands to use upcoming infrastructure legislation to expand Medicare eligibility and benefits, force negotiations over Medicare. drug prices and strengthen Obamacare subsidies.

Health care advocates warn Democrats have little time to deal with stalled progress in the expansion of Medicaid – seen as the biggest unfinished part of the Affordable Care Act – as the party controls Washington for the first time since the law was passed ten years ago.

“Now is the time,” said Judy Solomon, senior researcher at the Left Center for Budget and Policy Priorities. “It’s probably the only time we’ll have in years.”

The White House has taken a largely passive approach to talks about an alternative to the Medicaid expansion, as it has done with other big healthcare proposals Biden has campaigned on. While Biden’s budget proposal on Friday reiterated his support for these ideas, including closing the Medicaid coverage gap, it lacked specifics. The only major health promise that Biden has proposed to include in major economic legislation is the one considered the least politically confrontational: to make permanent the temporary expansion of financial aid from the recent Covid relief plan for people who buy drugs. Obamacare health plans.

“The president has always supported coverage of this population,” said an administration official when asked about the administration’s plans in states blocked for the expansion of Medicaid.

Congressional panels with jurisdiction over Medicaid, the House Energy and Commerce Committee, and the Senate Finance Committee, led the work on the issue. Committee chairs and Pelosi have not spoken publicly about their plans as staff work on details.

Support for a federal workaround was boosted significantly this week when the Sens. Georgia’s Raphael Warnock and Jon Ossoff, whose elections put Democrats in control of Washington, have urged leaders to include politics in infrastructure legislation. The confirmation by the Senate this week of Chiquita Brooks-LaSure to lead the federal Medicare and Medicaid agency is also expected to accelerate the Biden administration’s work on health coverage policies.

The renewed push to insure people in expansion lockdowns comes after those states largely ignored new financial incentives to expand Medicaid that were included in the Democrats’ stimulus package. The law provides for a two-year increase in federal Medicaid payments to developing states, in addition to the generous federal matching they would already receive to cover the growing population.

Of the recalcitrant states, only the Wyoming legislature seriously considered an expansion bill this year, but it died in the Senate after being passed in the House. And recent moves in other states have shown that expansion still faces tough hurdles across the country.

In Wisconsin, Republican lawmakers this week quickly closed a special session of Democratic Gov. Tony Evers called to consider an expansion. In Missouri, the state faces a lawsuit after Gov. Mike Parson refused to implement an expansion that voters approved last summer. And in Mississippi, advocates halted a campaign to put Medicaid expansion on the ballot next year after a state Supreme Court ruling made such initiatives impossible.

“What just happened in Wisconsin and Missouri gives momentum to the effort because it is clear that where Republicans can stop this in recalcitrant states, they will,” said Brad Woodhouse, chairman of the group. liberal Protect Our Care which is closely linked to Democratic leaders. in Congress.

Policy making remains difficult, however. And while Congressional Republicans have given up on trying to repeal Obamacare, they are not expected to support that effort.

Biden’s budget calls for the creation of a federal public health insurance option in recalcitrant states that would offer free coverage modeled on Medicaid benefits. States that have already scaled up – and are funding 10% of program costs – would receive unspecified “financial incentives” to deter them from dropping coverage.

The idea would likely attract rapid opposition from hospitals and health insurers, who support the expansion of Medicaid but oppose a public option that would eat away at their profits.

Chip Kahn, president of the Federation of American Hospitals, said it would be difficult to implement a new system of coverage without creating a financial imbalance between states that have extended Medicaid and those that have not.

“The fact that not all states have implemented the ACA Medicaid expansion means that there are inequalities among eligible Americans,” said Kahn, whose group represents for-profit hospitals. “But the problem is that trying to rig a solution for states that have remained outside of ACA Medicaid would then create inequalities in funding and rules between states that have expansion and those that do not. . “

Another idea is to expand Obamacare’s grants to allow low-income people in non-expanding states to have free private coverage in statutory insurance markets. Currently, people earning below the federal poverty line, or roughly $ 13,000 per year, are not eligible for Obamacare grants. Extending these grants would be expensive, as private plans cost the government much more per person than Medicaid or Medicare.

A third idea from Doggett, the chairman of the Ways and Means health subcommittee, would seek to bypass state opposition by allowing counties and other local governments to hyperlocalize Medicaid. This would still leave large gaps in coverage and could be difficult to implement.

As of Thursday, nearly 60 civil rights and advocacy groups, including the NAACP, The Arc, Planned Parenthood, and the Whitman-Walker Institute, in a letter urged lawmakers to expand coverage in recalcitrant states “as part of the clawback legislation this year.”

“Congress has a responsibility – which it has exercised in the past, in some of its proudest moments – to intervene in national policies to ensure that everyone is treated equally, regardless of state. or the territory in which they live, ”they wrote.

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