Policy Analysis | May 2015

The Status of Medicaid Expansion in SLC States

Lauren Greer

ALABAMA Governor Robert Bentley (R) indicated in December 2014 that he was open to the possibility of Medicaid expansion in the form of a state-designed program that uses private sector insurance and imposes work and job training requirements on the recipients. Governor Bentley has signaled that he may ask the federal government for a block grant to accomplish this expansion. The Alabama Legislature currently is considering a Joint Resolution that reaffirms their opposition to Medicaid expansion and urges Governor Bentley from taking any steps to expand the state's program. The resolution passed the Alabama Senate on April 21 and currently awaits action in the House.

ARKANSAS Arkansas has reauthorized funding for its private option alternative to Medicaid expansion through FY 2016. Under additional legislation passed during the 2015 session, the private option expansion will terminate on December 31, 2016, and a newly created legislative task force will make recommendations on alternative coverage models and reforms for the entire Medicaid program by December 31, 2015. Given that the General Assembly is not scheduled to meet again for a regular legislative session until 2017 (2016 is a fiscal session), Governor Hutchinson expects that a special session will be necessary to take action on the future of the state's Medicaid program.

According to the Arkansas Department of Human Services, 188,023 individuals have enrolled through the private option program, with an additional 25,117 medically frail individuals enrolled in traditional Medicaid, as of November 30, 2014.

FLORIDA Governor Rick Scott (R) initially announced his support of expansion in 2013, but legislative efforts to create the "Healthy Florida" program fell short with opposition from former Speaker Will Weatherford (R). Since 2006, Florida has held a special waiver to utilize a Low Income Pool (LIP) to provide healthcare services to Medicaid, underinsured, and uninsured populations. LIP funds, which total $2.2 million in state and federal funds for SFY 2014-2015, are used for supplemental payments to compensate certain service providers for the provision of uncompensated care. Following a one-year renewal of the LIP waiver by CMS, with a warning that it would not be renewed further, the Legislature is grappling with the possibility of a $1.3 billion budget shortfall without federal LIP funds when the program expires on June 30. The Florida Senate (R) has proposed the Florida Health Insurance Affordability Exchange Program (FHIX), which would use federal expansion funds to establish a state-run private insurance exchange for low-income residents with minimum monthly premiums and work requirements. The Republican-led House of Representatives remains steadfast in its opposition to Medicaid expansion. Following a stalemate in the Legislature, the House of Representative abruptly adjourned the 60-day legislative session three days before its scheduled conclusion. Governor Scott has filed a lawsuit against the federal government for allegedly coercing Florida into Medicaid expansion by withholding LIP funds. Tennessee and Texas may face similar challenges when seeking CMS reauthorization of uncompensated care pools. As of May 4, Texas had indicated that it will file an amicus brief supporting Florida in its lawsuit.

GEORGIA In 2014, with the support of Governor Nathan Deal (R), the Georgia General Assembly passed two pieces of legislation codifying its opposition to Medicaid expansion. HB 990 removes possible authority to expand Medicaid from all other entities by requiring legislative approval prior to taking such action. HB 943 prohibits the state or any of its units or political subdivisions from using money, human resources, or assets to advocate or intend to influence the citizens of the state to support the voluntary expansion of eligibility for medical assistance in furtherance of the ACA. The Georgia General Assembly took no additional action during the 2015 legislative session.

KENTUCKY With support from Governor Steve Beshear (D), Kentucky began operating a fully expanded Medicaid program on January 1, 2014. The state implemented a standard expansion and did not seek waivers for alternate models. According to pre-expansion estimates, roughly 300,000 Kentuckians would be eligible for coverage under the expanded programs. The most recent data from the Center for Medicare and Medicaid Services (CMS) estimates that 247,899 individuals, as of March 2014, were Medicaid expansion enrollees, which represents 23 percent of total Medicaid enrollees at the time.

LOUISIANA Governor Bobby Jindal (R) opposes Medicaid expansion. Facing a $1.6 billion budget shortfall, the idea of expanding the state's Medicaid program has gained more support from Louisiana lawmakers. However, several pieces of legislation that provided different paths for expansion were rejected in the House and Senate Health and Welfare Committees on April 29, 2015. On May 4, 2015, the House Appropriations Committee advanced a concurrent resolution, sponsored by Speaker Kleckley (R) and Speaker Pro Tem Leger (D), HCR 75, which provides a framework, but does not expand Medicaid, would allow hospitals to pool their money for use as the state's portion of matching funds under Medicaid expansion. Although the resolution passed this first hurdle without objection, the resolution requires a two-thirds majority vote for passage by the Legislature. If adopted, the state would have until April 1, 2016 to implement enhanced reimbursements through Medicaid expansion. Considering Governor Jindal's firm opposition to expansion, the 2016 deadline would provide the state's next governor, who will be elected in November 2015, with the authority to expand Medicaid under these provisions.

MISSISSIPPI Governor Phil Bryant (R) opposes Medicaid expansion. In 2014, the House defeated an amendment tying state appropriations to the expansion of Medicaid. In 2015, several pieces of legislation supporting the expansion were not brought for a vote in committee.

MISSOURI During his 2014 and 2015 State of the State addresses, Governor Jay Nixon (D) urged legislators to support Medicaid expansion and included expansion as part of his FY2016 budget proposals. Leaders in the House (R) and Senate (R) have said Medicaid expansion is not up for discussion during the 2015 session, with some senators vowing to filibuster any such discussion if it does come up. Although some changes to the state's existing Medicaid program currently are being discussed, they do not approach an expansion of the Missouri program.

NORTH CAROLINAIn recent months, Governor Pat McCroy (R) has indicated that he is open to considering alternative forms of Medicaid expansion, especially those with job or job-training requirements for eligibility, but he did not include provisions for Medicaid expansion in his FY2016-2017 budget proposal. In 2013, McCroy signed legislation to require approval from the General Assembly before expanding Medicaid. Speaker Tim Moore (R) and Senate President Pro Tem Phil Berger (R) both have said they oppose expanding the state's Medicaid program.

OKLAHOMA Governor Mary Fallin (R) opposes Medicaid expansion, making specific reference to the proposition in her 2014 State of the State address. Given that House Speaker Jeff Hickman (R) and Senate President Pro Tem Brian Bingman (R) also oppose expansion, the issue does not expect to gain traction during the 2015 legislation.

SOUTH CAROLINA Governor Nikki Haley (R) opposes Medicaid expansion. A bipartisan group of South Carolina Senators proposed a plan to utilize a combination of federal and state dollars to provide healthcare coverage to uninsured, working South Carolinians who do not qualify for the current Medicaid coverage or health insurance subsidies through the federal marketplace through a public-private partnership similar to the Arkansas Private Option plan. The Healthy SC plan initially was proposed as a budget proviso, but was withdrawn for consideration as standalone legislation later in the 2015 session.

TENNESSEEGovernor Bill Haslam (R) called for a special session in early February 2015 for the purpose of considering the Insure Tennessee expansion plan. During the brief special session, the proposal was defeated by a vote of 7-4 in the Senate Health and Welfare Committee on February 5, 2015, effectively ending discussions before the proposal was brought to a vote in either chamber. Had the General Assembly approved the plan, the state would still have to submit its proposal to CMS for official approval of the waiver amendment.

Insure Tennessee has reemerged a few times during the state's 2015 regular session with only marginal improvements in success. Senate Joint Resolution 93 passed the Senate Health and Welfare Committee on March 25, but subsequently failed to pass out of the Senate Commerce and Labor Committee. The General Assembly adjourned the 2015 session without taking a full House or Senate vote on the Insure Tennessee plan.

Like Florida and Texas, the federal government has warned Tennessee that its failure to expand Medicaid could negatively impact federal funding for its uncompensated care pool.

TEXAS Continuing the trend of long-time Texas Governor Rick Perry, newly elected Governor Greg Abbott (R) has said that he does not support the Medicaid expansion. In late 2014, the 15-member Texas Institute of Health Care Quality and Efficiency, a board of medical professionals appointed by then-Governor Rick Perry (R), recommended that the state's health commissioner be allowed to negotiate with the federal government a Texas-specific solution to expand health coverage with available federal funds. The Institute was created in 2011 to identify evidence-based approaches to improve healthcare and reduce costs. Any recommendations by the Institute are not binding on the Legislature, which has maintained its opposition to Medicaid expansion.

Texas has renewed its request to the federal government for greater flexibility in spending of Medicaid dollars without expanding the program, which includes requiring Medicaid beneficiaries to seek employment as of condition of obtaining coverage. Previous requests by the state have been rejected by the current and former presidential administrations. Similar to Florida, a Texas waiver, valued at $29 billion, that uses federal funds to reimburse hospitals for providing uncompensated care is set to expire in September 2016. The state has been warned that its failure to expand Medicaid would be taken into consideration when deciding whether to extend this waiver, possibly to its detriment. On May 4, 2015, Texas indicated that it would file an amicus brief to support Florida in its lawsuit against the federal government for coercion.

VIRGINIA Governor Terry McAuliffe (D) is a strong supporter of Medicaid expansion and has had some bi-partisan support in 2014 for an expansion from the Senate. Following a stalemate last year with the expansion tied to the state's budget, the House reiterated its opposition to expansion during the 2015 legislative session. Neither the House (R) nor the Senate (R) included Medicaid expansion in their budget proposals for the 2015 session and ultimately did not include it in the final budget.

WEST VIRGINIA With support from Governor Earl Ray Tomblin (D), West Virginia began operating an expanded Medicaid program on January 1, 2014. The state implemented a standard expansion and did not seek waivers for alternate models. Pre-expansion expectations estimated about 63,000 new enrollees during the first year, with 118,000 expansion enrollees expected by 2018. Recent figures from CMS estimate that 103,662 individuals, or 22 percent of total enrollment, had enrolled in Medicaid under the expansion as of March 2014.

Accurate as of May 5, 2015