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Does any of this sound like “Medicaid Expansion” to you?

So Wonkblog, TPM, and BOR, all riffing off the same news story in which Greg Abbott had a clandestine meeting with Houston-area legislators and may have said some things that made them think he might be open to “Medicaid expansion”, are all talking about it as though it’s a thing that could happen. Here’s Wonkblog, which had the most detailed report:

It's constitutional - deal with it

It’s constitutional – deal with it

If Abbott did back Medicaid expansion funding, worth about an estimated $100 billion to the state over 10 years, it would be arguably the biggest “get” for the Obama administration since the Supreme Court made the expansion voluntary more than two years ago.

As Texas attorney general, Abbott joined the lawsuit against Obamacare that reached the Supreme Court in 2012. His predecessor, Gov. Rick Perry, has been one of the most outspoken opponents of the Medicaid expansion, and Abbott campaigned against the Medicaid expansion leading up to the November election.

According to the Texas Tribune report, he’s interested in the expansion deal Utah Gov. Gary Herbert struck with the Obama administration after months of negotiations. Herbert’s plan would use Medicaid expansion dollars to buy private coverage for low-income adults earning below 138 percent the federal poverty level, or about $16,100 for an individual, with some cost-sharing requirements.

Of the 23 states that haven’t expanded Medicaid, Texas by far has the most low-income adults living in the “coverage gap” – people who earn too much to currently qualify for Medicaid but don’t earn enough to receive subsidies to purchase health insurance through Affordable Care Act exchanges. About 948,000 adult Texans fall into this category, or about 25 percent of all Americans in the coverage gap, according to the Kaiser Family Foundation.

It’s still not clear whether Abbott’s thinking on Medicaid has changed. He’s recently called for a block grant of current Medicaid funding, which would be a lump sum to run the health-care program with far less oversight from the federal government — an idea that doesn’t sit well with Democrats. And Abbott has said Texas couldn’t afford the expansion when the federal funding match drops to 90 percent of the program’s cost in a few years.

The expansion issue is far from dead in Texas. A legislative health committee earlier this month rejected the traditional expansion but left the door option for future waiver negotiations with the federal government. A separate federal Medicaid waiver, worth close to $30 billion, could provide a major leverage point for the Obama administration when the waiver expires in 2016.

I’ve linked to it before, but here’s that Senate interim committee report, which covered other topics including Medicaid. The sum total of what they wrote about Medicaid is only nine pages, beginning on page 22, so you can read it all yourself if you want, but I’ll save you some time and reprint the recommendations here:

1. Texas should encourage congressional action to operate Medicaid as a block grant program and should simultaneously continue to pursue a waiver from the Centers for Medicare and Medicaid Services (CMS) to allow the state increased flexibility in the operation of our Medicaid program. While the delivery of Medicaid funds through a block grant is ultimately a decision of the U.S. Congress, the state should actively urge such action at the national level. Additionally, HHSC should continue to seek a waiver from CMS that will allow Texas to contain costs and increase personal responsibility by enacting cost sharing requirements, tailoring benefits to more closely align with individual needs, enhancing efforts to prevent fraud, waste, and abuse, and eliminating unnecessary administrative costs.

2. Support successful programs and entities that have local buy-in and include local funding sources.

  • Successful programs that serve the uninsured and are funded through state and local sources, such as mental health services offered through Local mental Health Authorities (LMHAs) and county indigent programs, should be supported and potentially expanded by the Legislature.
  • Programs that enable low-income families to access private market health coverage such as the Health Insurance Premium Payment (HIPP) program should be promoted and expanded. This program reimburses families of Medicaid-eligible clients for their share or a portion of their share of an employer-sponsored health insurance premium, only in cases when the state has determined that paying the premium is more cost-effective than enrolling the Medicaid-eligible family member in the Medicaid program. In Fiscal Year 2013, there were 7,194 active HIPP cases serving 9,657 Medicaid-eligible individuals and 26,409 total clients. Expansion of the HIPP program should be considered as a way to connect family members of Medicaid-eligible individuals to affordable private health insurance.
  • Texas should support settings that serve high numbers of uninsured Texans, such as Federally Qualified Health Centers (FQHCs). FQHCs provide a medical home for many Texans without health insurance. FQHCs are facing a “fiscal cliff” in 2016, when the federally-funded FQHC Trust Fund is expected to be discontinued. Texas should advocate for continued funding for the Trust Fund and supply state funds, as available, to support this vital part of our safety net.

So I ask again, does any of that sound like “Medicaid expansion” to you? Some of these may be good ideas – I’m not enough of a wonk to say – but it’s not clear to me how expansionary any of them are, or what any of them have to do with “Medicaid”. I get that there’s an aversion to using the term “Medicaid” in any policy description, but either the goal is to provide health insurance to most if not all of the people who would be eligible for Medicaid under an ACA-style expansion or it’s not. I don’t see anything that points in that direction, and until I hear Greg Abbott use words that signal an intent to, you know, EXPAND health insurance coverage in some form, then I say deep skepticism is the rational response.

Now, I do appreciate some journalistic attention to this, however thin the reed is that we’re all hanging on, so let me suggest a couple of questions that could be asked the next time Abbott deigns to talk to the press about this, or anything else.

1. Is your primary goal still to seek block grants for Medicaid? How will that meet the goal of covering more Texans?

2. What prompted your change in thinking on this?

3. How will you overcome the opposition of your Lieutenant Governor, many of the Republicans in the Legislature, and your ideological allies Such as the TPPF?

Those last two questions are on the assumption that Abbott is indeed interested in pursuing something other than block grants. Which, to be clear, I still think is what he intends to do. As such, those questions are likely moot, but let’s keep them in our back pockets just in case. I don’t expect to need them, but what the heck. In the meantime, as I’ve said before, let’s keep our eye on the ball.

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