California politicians and interest groups have been working overtime to figure out a way to fix an illegal Medicaid provider tax—the subject of my recent Mercatus Center study. These taxes are problematic because they are generally accompanied with the guarantee of increased Medicaid payments to the providers paying the tax—payments largely financed with federal matching funds. As a result, provider taxes, which reek of government favoritism because of how the benefits often target select providers, raise Medicaid spending.
California’s tax is illegal under federal law because the state was holding numerous insurers harmless from the tax that should not have been. The state has recently come up with a revised tax plan that it is submitting for federal approval.
Six of the 32 states implementing the Affordable Care Act’s Medicaid expansion to date have done so through Section 1115 waivers. Using these waivers, the Centers for Medicare and Medicaid Services has approved terms that extend beyond the flexibility provided by federal law. Section 1115 waivers authorize research and demonstration projects that, in the view of the Health and Human Services Secretary, further the purposes of the Medicaid program. The ACA implemented new requirements for these waivers, including that states must have a publicly available, approved evaluation strategy. States also must submit an annual report to HHS that describes the changes occurring under the waiver and their impact on access, quality, and outcomes.
State Medicaid agencies say Congress’ decision to suspend the Affordable Care Act’s tax on health insurers for one year is a good first step, but they are pushing for its permanent repeal.
While most private health insurance plans have had to pay the tax themselves, states that contract with Medicaid managed-care plans have had to cover the premium tax to ensure that the health plans receive actuarially sound rates. Thirty-eight states and the District of Columbia contract with Medicaid managed-care plans.
While many Americans are obsessively following the presidential primary campaign, health policy experts are concerned about little-noticed Republican primary contests for state legislative seats that could determine the fate of Medicaid expansion in Arkansas and other states.
In Arkansas, Tuesday’s elections include several primary contests pitting Republican state lawmakers who voted for Medicaid expansion to low-income adults against GOP primary challengers who promise to end the state’s coverage expansion. Republican Gov. Asa Hutchinson needs votes from 75% of the GOP-controlled Legislature to win approval for his conservative changes in the state’s Medicaid expansion program, or else the expansion will end this year. So he can’t afford to lose any expansion allies.
Right now, the New Hampshire House is considering reauthorizing Medicaid expansion under ObamaCare. Doing so would be a big mistake that our state simply cannot afford to make.
In 2014, New Hampshire expanded its Medicaid program under the Affordable Care Act. Previously, to qualify for Medicaid a person needed to be both poor and medically needy (pregnant women, children or disabled). Under Medicaid expansion, a person needs only to be below 138 percent of the federal poverty level. That means that able-bodied adults, even above the poverty line, would have taxpayers buy health insurance for them.
The measure that was passed in 2014 ends on Dec. 31, 2016. That means that if the program is not reauthorized, eligible able-bodied adults would no longer have taxpayer-funded health insurance.
The reauthorization bill currently sits before the House Finance Committee to make sure our Medicaid policy is on a solid financial footing. Given the total size of the program – close to $500 million per year – this seems like a prudent step.
Funding a problem doesn’t solve a problem. There are ways to make health care more affordable and accessible with less government dependence. For starters, Congress should seriously reconsider the way the program is financially structured so states can be granted more flexibility to devise ways that can improve the value Medicaid brings to its beneficiaries.
The other component involves reducing regulation to make medical care more affordable, like repealing Certificate of Need, permitting mid-level providers to practice within their full scope of authority, exercising right-to-try laws, reducing the number of health insurance benefit mandates, or changing the federal tax code to allow the direct primary care market to expand.
Medicaid’s complex federal-state financing structure has long created perverse incentives that discourage efficient care. Key to the problem is the federal government’s uncapped reimbursement of state Medicaid expenditures, which encourages states to artificially inflate their Medicaid spending. Such schemes have significantly increased over the past several years and they likely add tens of billions in generally low-value Medicaid spending each year.
This study examines states’ use of accounting schemes to inflate federal Medicaid reimbursements. The study focuses on the largest of the current schemes, provider taxes. These are assessments states levy on healthcare providers, often accompanied by the explicit or implicit guarantee of increased Medicaid payments to those same providers, financed from the federal matching funds. The study provides an economic and political analysis of these taxes and other strategies that states have employed to maximize federal Medicaid reimbursements, and recommends reforms. It contains an appendix with a case study of Arizona, which shows how the state imposed provider taxes to pay for Medicaid expansion.
The Obama administration released its proposed budget for 2017 this week. It includes a host of health care-related proposals, including new initiatives to increase access to mental health care, expand opioid abuse treatment, fight antibiotic resistance, address the Zika virus threat, and fund a “cancer moonshot.”
The budget also contains a number of proposals relevant to Affordable Care Act provisions. It proposes providing 100% federal funding for state Medicaid expansions for three years regardless of when the state decides to expand.
It would also modify the high-cost employer health plan (“Cadillac”) tax to take account of geographic differences in health care costs; specifically, it would set the threshold when the tax begins to apply at the greater of the current statutory dollar threshold or a state’s “gold plan average premium.”
The HHS Budget in Brief includes a request for $2.1 billion to fund the federally facilitated marketplaces and oversight of the state marketplaces.
The budget anticipates the collection of $4.335 billion and expenditure of $4.560 billion in 2017 for the transitional reinsurance program.
People are starting to get excited about another ObamaCare work-around: The section 1332 waiver. This refers to a section of ObamaCare that allows states great flexibility in how they deliver ObamaCare within their borders. The curious thing about section 1332 waivers is that they can only be issued as of January 1, 2017.
Why? Why not allow states to get section 1332 waivers as of October 2010, when ObamaCare’s first regulations took effect? Or January 2014, when the gushers of tax credits began to flow through the exchanges? Who knows? Maybe the administration just thought they needed a few years for the cement around ObamaCare to solidify.
Newt Gingrich and Tom Daschle have co-authored a report on how states can use section 1332 waivers to execute policy preferences either to the left or the right of ObamaCare. Anne Phelps of Deloitte & Touche LLP has also written a report describing the benefits of using a section 1332 waiver.
Unfortunately, while many 2016 presidential candidates have backed the “repeal” part of the “repeal and replace” equation, few have addressed how they would start over.
They would do well to follow the advice of The Heritage Foundation. The think tank’s soon-to-be-released policy handbook for candidates, Solutions 2016, lays out the “then what” reforms candidates should be talking about:
- Remove regulatory and policy obstacles that discourage choice and competition.
- Encourage personal ownership of health care by reforming the tax treatment of health care.
- Transform health care coverage for low-income Americans by reforming Medicaid as a true safety net and glide path out of poverty.
- Modernize Medicare program to meet the demographic, fiscal, and structural challenges that threaten to bankrupt the system.