By Tom Baxter
Even when it seems the border wall, the Mueller probe and the Korean summit have overshadowed the healthcare debate, it remains a constant, driving force in American politics. The battle rages on, in venues outside Washington.
Since the collapse of the last Republican effort to replace the Affordable Care Act in the summer of 2017, the debate has shifted to the state legislative level. In state after state, Democrats in favor of accepting expansion of the state’s Medicaid program under the provisions of the ACA have been pitted against Republicans favoring various kinds of waivers which let the state write its own rules while still receiving federal bucks.
Framing it that way is a little misleading, however. There are 14 remaining states which haven’t accepted the deal offered under the ACA, but since these also include the most Medicaid-dependent states, their Medicaid programs are expanding whether they accept the expanded funding or not. In South Carolina, for instance, Medicaid enrollment has grown by more than 260,000 and state Medicaid spending has grown by 32 percent over the past eight years. That’s what is compelling Republican-majority legislatures in these states, unwavering in their opposition to the ACA just a few years ago, to suddenly be talking so much about waivers.
Keep in mind that the effect of Gov. Brian Kemp’s Patients First Act would be to rescind the 2014 legislation in which the Georgia General Assembly took the decision-making power on Medicaid away from the governor’s office to insure that no future, possible Democratic, governor could ever veer from the anti-Obamacare path. (It also took then Gov. Nathan Deal off the hook for the remainder of his term.)
The bill would give the governor the authority to spend $2 million on a study of how to customize a waiver application.
“He wants to do it the Georgia way,” Senate Health and Human Services Committee Chairman Ben Watson said recently on GPB’s “Lawmakers,” drawing a line that you can hear being drawn around the country.
Next door, Tennessee has the mother of all waivers, granted long before Obamacare: the 1994 waiver which allowed the state to set up its expanded TennCare system. This year, Republicans have proposed seeking a new waiver for a block grant to finance TennCare, which Democrats have panned as an attempt to counter their bill approving a full Medicaid expansion. At its root, this is much the same debate as the one in Georgia.
In Utah, the legislature drew the line even after voters there approved the full ACA Medicaid expansion. Despite the vote, Utah Gov. Gary Herbert has signed a bill with a scaled-back expansion, allowed under a waiver which was quickly approved by the Trump administration after the vote last year. A similar effort to roll back a voter-approved expansion appears to have failed in the Idaho legislature.
It was interesting to hear Watson say in that “Lawmakers” appearance that in a conference call, the White House had voiced its approval not only for the Republican waiver bill, but also the legislation that would replace the current Certificate of Need system. That’s a lot farther into the weeds than you might expect the White House to wander, and an indication this administration, thwarted in Congress, is still determined to shape healthcare policy.
At the Trump administration’s urging, several states have applied for waivers allowing them to impose work requirements on adult Medicaid recipients. In Arkansas, the first state to implement the requirement, more than 18,000 people lost coverage because of the requirement in 2018. About 8 percent of that group had met the requirement and were back in the program by the beginning of this year.
All this jousting back and forth between waivers and expansions presumes that the ACA will continue to be in effect, even though a federal judge in Texas ruled the entire law unconstitutional in December. It’s widely thought that ruling will be overturned or modified, but if it stands, both sides in the Medicaid debate will be in uncertain territory. You can no more obtain a waiver from a law that no longer exists than you can expand it.