How far to expand Medicaid coverage for poor people under the new federal health-reform law is turning into a major question in many states. In Washington, it is shaping up as a major question for the Legislature next year.
Majority Democrats and Republicans are sharply split, and their differences came into sharp focus last week during a legislative work session on health reform at the state Capitol. At issue was how far the state should go in providing taxpayer-paid health care for poor people who, if uninsured, drive up costs for everyone else by going to hospital emergency rooms.
Medicaid now serves nearly 1.1 million Washingtonians, and upward of 1 million more could enroll in January 2014 under the federal Affordable Care Act. Most of those costs would be paid by the federal government, although the states share would top out at 10 percent in 2020.
Doug Porter, director of the state Health Care Authority and overseer of state Medicaid programs, told a joint House-Senate committee hearing Wednesday that projections show new enrollment is likely to be closer to 328,221, and he believes any new costs may be offset by savings from better-managed cost and shifting some current state costs to the federal government.
It may be a wash, Porter said to skeptical Republicans on the committee during a three-hour work session.
The more you talk, the nervous-er I get, Republican Sen. Linda Evans Parlette of Wenatchee told Porter at one point in his presentation.
Porter discounted what some are calling the welcome mat effect in which people now eligible for coverage come into the system under pre-reform rules under which the state must pay half of the cost. Porter said most who would come into the system that way are children, who cost less. But reliable budget numbers are not going to be available until perhaps November, which is when the general election decides who is calling the shots in Olympia.
In the meantime, Parlette and Sen. Randi Becker of Eatonville want to slow down the states transition work under the Affordable Care Act. Parlette claims there may be huge state costs and is raising questions about how rural hospitals might be affected by the new rules that the state is still trying to interpret.
Becker wants assurances that clients in Medicaid would have access to doctors of their choice. But Gov. Chris Gregoire wants to push ahead as federal agencies work to interpret the new law while getting input from states such as Washington that are moving ahead, according to Jonathan Seib, the governors health-policy adviser.
Seib said there are risks if the state delays and is not ready to meet reform deadlines in January 2014. Democratic Rep. Eileen Cody, who chairs a health care committee in the House, also is pushing forward. She thinks the benefit of getting thousands more people covered outweighs the relatively small costs the state incurs after 2016.
From everything weve seen, itll actually save us money or at least break even I cant imagine we wont move forward, Cody said after the work session, acknowledging that the November election is weighing on the debate.
I think until after November were going to still have everybody posturing. Hopefully after that, we can just move on. Everybody will get over it, Cody said.
The party-line differences mirror those of the leading candidates for governor. Democratic Party nominee Jay Inslee says it is worth it to add potentially 400,000 people to coverage under a full expansion covering low-income people up to 133 percent of the poverty line, including childless adults at low state cost.
Inslee said the uninsured add $1,000 a year in insurance costs to everyone who has coverage now.
But leading Republican candidate Rob McKenna says he doesnt want to commit the state until he is sure the state can afford its share of the costs and pay for K-12 school upgrades. McKenna says that if elected, he would work with legislators to answer the affordability question. The same question is being answered in different ways around the country. Floridas governor has said no to an expansion, while others are considering their options.
And 13 states actually are reducing Medicaid services to deal with current budget shortfalls even before considering the federal reforms, according to a report last week by Kaiser Health News.