One thing is guaranteed: If Democratic state Rep. John Bel Edwards is elected governor, Louisiana would expand Medicaid rolls sooner rather than later.
The three main Republican contenders indicated they are open to expansion of the government insurance program to serve more of the state’s uninsured. But they are fuzzy on what form it would take and talk about financial concerns.
Medicaid is the state and federal government program that pays the health care costs for about 1.4 million — about one-fourth of Louisiana’s population — low-income residents. A key part of the federal Affordable Care Act is to expand the qualifications of Medicaid to allow the sign up of about 300,000 Louisiana residents who now make too much money to qualify but too little to buy adequate insurance on the private market.
Edwards wants immediate expansion of the state Medicaid program, which is administered under contract by private companies. That would not require federal approval, expediting Louisiana’s participation in the program, for which the federal government would pay about 90 percent of the costs.
U.S. Sen. David Vitter, Lt. Gov. Jay Dardenne and Public Service Commissioner Scott Angelle, all Republicans, says what they have in mind would require special federal permission, which can take a long time.
Vitter and Angelle favor a “work requirement” in order for people to participate in the expanded Medicaid program.
Jindal has rejected state participation in what is also called “Obamacare,” saying the Medicaid system is broken and state costs would skyrocket. Started in 2014, the first three years of expansion is federally funded. By 2020, the state’s maximum share of costs would climb to 10 percent. In traditional Medicaid, the state pays 37 percent of the costs.
The Republican-majority Legislature blocked several attempts by Edwards and other Democratic legislators to expand Medicaid. But a crack appeared in the 2015 session when legislators overwhelmingly approved a measure that could generate some of the dollars to fund the match. The caveat is that expansion would have to occur by April. If a new governor does not meet the timeline, a new proposition would have to be approved by the Legislature.
The Legislative Fiscal Office estimated that expansion would decrease state expenditures by $102 million to $165 million over five years, plus more people would be insured. The estimates are based on signing up 298,000 people now uninsured between ages 19 and 64 and living in households with incomes up to 138 percent of the federal poverty level. For a family of one, income could reach $16,105 per year, and for a family of four, annual income could be up to $32,913.
“I will expand Medicaid because it’s the right thing to do. We have already lost out on $3.2 billion,” Edwards said.
Edwards noted changes already made to Medicaid such as contracting private companies to do what the state once did and to put heavy emphasis on preventive and primary care. “We have already transformed the way we deliver care,” Edwards said, referring to Jindal’s privatization program called Bayou Health.
“Why wouldn’t we expand it? We have been giving our tax dollars to other states too long,” he said.
Thirty states and the District of Columbia have opted to embrace Medicaid expansion since its start in 2014 — tapping into 100 percent federal funding, which lasts through 2016. Some have received special federal permission to implement their own models, including some insurance, private market-based plans.
Vitter said he would not rule out Medicaid expansion. He said it must be done “on Louisiana terms, certainly not Barack Obama terms.”
Vitter said there must be identified funds up-front to provide Louisiana’s matching dollars and expressed skepticism that the matching funds identified by the Legislature would be sufficient.
The 2015 Legislature approved a resolution under which hospitals would access a fee on themselves to generate money to cover the state match. The state would have to agree to change Medicaid income qualifications to sign up uninsured people.
“I want to reform Medicaid, not expand the present system,” Vitter said. He said he wants a “work requirement” but doesn’t provide specifics.
Angelle too mentions a work requirement as part of any plan he would embrace.
The federal Centers for Medicare and Medicaid Services has not approved a work requirement as part of any state’s waiver request seeking to start an expansion model of their own. Edwards said it is unnecessary because the uninsured are working.
Angelle said he wants to provide coverage to people who make too much today to get Medicaid coverage, such as day care and restaurant workers, “but not fortunate enough to have employer-sponsored health care.”
Jindal eliminated employer-sponsored coverage that had been offered through Medicaid.
If the federal government “changes the rules, I want to get out in a very easy, quick way,” Angelle said.
“I do believe we need to expand coverage,” Angelle said. But it should be “a market-based” approach, he said.
As governor, Dardenne said day one he would appoint a task force of experts in the health care arena whose charge would be to come up with a Medicaid expansion plan within 30 to 45 days.
He said he would seek “conditional approval” quickly from the federal government for whatever plan develops. The request would include an escape clause, he said.
Dardenne said Louisiana needs flexibility given the financial challenges the state is facing in the health care arena with public-private LSU hospital partnerships and the Bayou Health private Medicaid insurance program in their infancy.
“We may want a pay for performance model,” Dardenne said.
Follow Marsha Shuler on Twitter @MarshaShulerCNB. For more coverage from the State Capitol, follow Louisiana politics at http://blogs.theadvocate.com/politicsblog/.