The Medicaid expansion provision of the Patient Protection and Affordable Care Act (PPACA) "is a great deal for the states," and will ultimately be implemented by most, if not all, the former head of the federal agency overseeing implementation of PPACA said today.
"The irony of those states that decide we are not going to sign on to the Medicaid expansion is that the governors who are doing so are saying, 'We're not going to insure our uninsured people, but we are still going make our taxpayers pay federal taxes to insure uninsured people in other states,'" said Jay Angoff, a lawyer with Mehri & Skalet in Washington and the first head of the Center for Consumer Information and Insurance Oversight (CCIIO) at the U.S. Department of Health and Human Services (HHS).
|North Dakota state Rep. George Keiser, R-Bismarck, listens to testimony about new federal health care legislation in 2010. (AP Photo/Dale Wetzel)|
"That's crazy," Angoff said. "That's why we see governors like Rick Scott in Florida and John Kasich in Ohio, who have been against the Medicaid expansion, have decided to accept it."
"That is why I think ultimately most, if not all, governors will accept it," Angoff said.
Angoff made his comments as part of a National Press Club Newsmakers program, held today, on "Obamcare on the Ground, How is the Affordable Care Act Taking Shape in the States?"
Angoff said he can’t understand why only 24 states have opted in to the Medicaid component of PPACA as of March 4.
“It is such a good deal,” he said. “Not only do the uninsured benefit but the hospitals benefit,” Angoff said.
He said the hospitals “really need it because they are losing one stream of funding and they need this to make up for it, and it more than makes up for it.”
Angoff said that even business groups, even the Chambers of Commerce in many states are very supportive of Medicaid.
“That is why we think most states, if not all states, will ultimately support expand Medicaid,” he said.
Another speaker, North Dakota state Rep. George Keiser, a Republican who is a former president of the National Conference of Insurance Legislators, lauded PPACA, even though he represents a conservative state that rejected his proposal to establish a state exchange.
Like the Obama administration, Keiser refers to the law as the ACA.
"From my perspective, the ACA was an attempt to use a patchwork approach to save the current health care system," Keiser said.
"The old system wasn't working," Keiser said. "Whether it works or not, I don't know. But it is an attempt. But this is what the affordable care act is trying to do."
See also: Texas House opposes Medicaid expansion
Sen. Neil Breslin, D-N.Y., also lauded the Medicaid expansion proposal.
“The Medicaid expansion was “a tremendous windfall for us,’ Breslin said.
“The uninsured are the ones who get into the most trouble in terms of sickness,” Breslin said. The premise is that if you insure them, those who are obese, have heart and diabetes problems,” will be better served.
“To me, the end result is that there will be significant savings in healthcare costs as a result of Medicaid expansion,” Breslin said
Angoff, because of political pressures, was ultimately shifted to another job, and OCIIO was moved under the funding of the Centers for Medicare and Medicaid Services to thwart concerns within the Obama administration that Republicans would try to kill the bill by ending funding for it. Steve Larsen, former Maryland commissioner, was later named to be the director of OCIIO; he left last year.
Another speaker, Mila Kofman, executive director of the Washington, D.C., Health Benefit Exchange, said the exchange in D.C. will be up and running by the target date of October.
The health exchange system is scheduled to be launched Jan. 1, 2014, under a key provision of PPACA.
Angoff agreed. He also said that, unlike news reports, HHS expected that most states would rely on federal, rather than state exchanges.
“During the three years I was at the agency, we always assumed that a large number of states would opt-in to the federal exchanges,” Angoff said. "This is not a surprise,” he said. “HHS has the expertise to implement the exchange system.”
Angoff appeared to believe it was bizarre that more states didn’t take the money HHS provided, billions of dollars, to implement their own exchanges.
He said the money for the states was appropriated funds, but HHS had to fund the technology, both hardware and software, to create federal exchanges out of its own appropriations,” Angoff said.
“It would have been great if there was a designated stream of funding for HHS to establish exchanges,” Angoff said.
But, he said, HHS has the resources to ensure that the exchanges are up and running by the Oct. 1 deadline.
“HHS has the means to do it and they will do it,” he said. “The marginal cost of adding one more state to the fed exchange once the technology, the template work, has been completed.”
Keiser said that under the law, states can go back to create their own exchanges as of 2017, but it makes little sense to do it, for a host of reasons.
Both noted that as of 2015, the exchanges have to be self-supporting, which means that states that want to go back in 2017 to establish their own exchanges after opting out the first time have to pay for it themselves.
“[Keiser] makes a lot of sense,” Angoff said. “I see no benefit for North Dakota to necessarily go to a state exchange once the federal exchange is up and running."
Keiser noted, for example, that, by law, each state has to establish its own essential benefits criteria.
He said North Dakota had opted for a basic benefit package that included the least possible number of benefits. But, Keiser said, the North Dakota plan is designed so that insurers can market their product to add additional benefits.
“Insurance companies are very good at packaging their products and marketing them to add additional benefits,” Keiser said.
Keiser’s justification of PPACA was interesting because he comes from such a conservative state.
He said that from his perspective, the healthcare law was an attempt to use a patchwork approach, to save the current healthcare system. “What systems did we have for funding health care?” Keiser asked.
“I really compliment HHS,” Keiser said. They looked at this from 30,000 feet and said, where are the doughnut holes?”
“We have small groups, individual market, small group markets, Medicare, Medicaid, the State Children’s Health Insurance Plans, workers compensation and auto insurance,” he said.
He asked, “What didn’t we fund? We need to cover the 26-year-olds. These kids are going to college a little longer, they are very healthy, but we need to bring them in under their parents.
“What did the Medicaid expansion do? It filled another doughnut hole. What did the penalties, the incentives on providing insurance with subsidies do? It filled doughnut holes,” Keiser said.
In general, Keiser said, the bill was an attempt to look at the doughnut holes systemically, and tried to plug them.
“Will it work," he asked. “Well, the average family pays over $1,000 a year due to cost-shift from those who don’t have insurance and go to emergency rooms,” Keiser said.
Keiser also said at the hospital in North Dakota on which he serves as a board member, 6 percent of those visiting the emergency rooms as their medical plan have dental problems only. “There is not a thing you can do except provide them with medication,” he said.