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Coffee CAHC policy round-up: November 8, 2017

Coffee CAHC is a twice-weekly newsletter where we round up and comment on the latest health coverage policy developments both nationally and here in Maine. We hope you find these updates helpful!

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Coffee CAHC

115th Congress, 1st session

128th Maine Legislature, adjourned

 

Wednesday, November 8, 2017

 

Good morning from warm and beautiful New Orleans! Yes, I’m on the road again, this time at the Healthcare Value Hub Cost & Value conference, looking at how to tackle rising, unaffordable, and unsustainable costs in our health care system. It’s fascinating stuff – I’m learning a lot!

This morning, though, the topic on everybody’s lips down here? Maine! We’ll get to that in the state level section below.

 

National level

A perhaps surprising set of results from the first few days of Open Enrollment: record enrollment.

Despite the Trump Administration’s ongoing efforts to sabotage the ACA and do everything in their power to prevent people from accessing the health coverage that they are entitled to (and, boy, more on this in a second), it seems that the Marketplace is blowing previous year records for enrollment out of the water. Remember, this includes re-enrollments as well, and after 5 years, quite a few enrollees have figured out how the Marketplace works and know how to get themselves re-enrolled early on. Still, this is encouraging news.

In the less-than-encouraging-news camp, President Trump’s Center for Medicare and Medicaid Services (CMS) director, Seema Verma, has been making some pretty alarming statements over the past few days. Although here in Maine, they sound awfully familiar. In a nutshell, she’s basically said that she (and by proxy, the Trump Administration) don’t think that it’s Medicaid’s job to provide coverage to people. No, seriously.

OK, I’m exaggerating slightly, but only slightly. Let me give you some real talk here for a second.

I truly, genuinely believe that the fever-dream of this Administration is for the government to get out of the business of health care altogether. That was certainly what we saw in one ACA repeal bill after another this year, and now the Trump Administration is parroting what we’ve been hearing from the LePage Administration here in Maine for years: it’s working adults vs the disabled, the disabled vs kids, kids vs the elderly. They love to say that we can’t provide health care for group A without having to steal from the “truly needy” group B; then group B steals from group C, and on and on it goes.

Anybody wanna guess how that flimflam ends? Lemme clue you in: it ends with nobody getting health coverage at all, because of a furious ideology that wants to throw everybody to the wolves (except, of course, the hyper-rich, who always seem to make out just fine).

A few years ago, I would have sounded like a tinfoil-hat conspiracy theorist for saying things like this. But now, you don’t even have to take my word for it, because you can just take theirs. No bit of official dogma has turned my stomach quite like this choice little nugget from Administrator Verma in a speech earlier this week:

“We have a higher purpose than just handing out Medicaid cards and being a financier of healthcare. Medicaid is a promise, both to our beneficiaries and to the American people that fund our programs. Our promise to beneficiaries is that we will ensure that our programs address your specific needs and give you access to high quality healthcare. We will not just accept the hollow victory of numbers covered, but will dig deeper and demand more of ourselves and of you.”

“The hollow victory of numbers covered.” There it is. If you weren’t certain before, you can have no doubt now. The Trump Administration thinks that Americans getting health coverage is “hollow”. They think lives bettered, lives saved, are worthless if the government was involved. They think that people who need the government to be there for them when they need it are lesser than the rest of us. They want to demand more of them.

She was speaking, by the way, to a conference of state Medicaid directors.

The most polite word I can muster for this is that it’s gross.

OK – sorry, went on a rant there! The more concerning policy indicators from her speech and from CMS in general are a clear signal that they’re going to allow states to impose work requirements on Medicaid beneficiaries. That’s alarming, since Maine still has a pending 1115 Medicaid waiver that seeks to impose work requirements. An idea that utterly ignores, of course, that work requirements don’t work (and they don’t work because pretty much everybody on Medicaid who can work already is).

Well, let me rephrase that: work requirements don’t work if your goal is to put people back to work. They DO work, pretty well in fact, if your goal is to throw people off coverage.

You know what this reminds me of? It reminds me of President Trump shouting that his idea for how to deal with mass shootings is to strengthen mental health services – at the same time that his administration is intent on slashing and burning mental health services.

Or, closer to home, it’s like Governor LePage shouting that Medicaid recipients should work more, at the same time that he rejects $4 million in federal funding for job training (even the Trump Administration thought that one was inexcusable).

I think they’re hoping we’re too stupid to notice that they’re lying to us, and that we’re too callous to care about people getting health care.

But guess what?

 

State level

We noticed.

Oh, boy, did we notice.

After six years of fighting over it, and after the Governor stubbornly vetoed five different bills to do it, Maine voted overwhelmingly last night to implement Medicaid expansion in Maine.

(How overwhelmingly? I saw something floating around this morning that it may have been the largest margin for a citizen-initiated ballot initiative in, possibly, decades – but I haven’t confirmed that yet, so for now just go ahead and say that a ~60-40 win is pretty darn overwhelming.)

Unsurprisingly, the Governor – having lost this fight so severely at the ballot box, where Maine voters resoundingly rejected the lies and exaggerations he’s been shrilly spouting about this for the past few weeks (months?) (…years…) – has already belligerently announced his intent to ignore this new law unless his petty demands are met.

Let’s be clear, again (I feel like I’m doing a lot of “being clear” this morning): the Governor is prohibited from vetoing a ballot initiative. He can’t veto this. This initiative has been passed, and becomes law by mid-February.

Becomes law.

The Governor – this Governor or any other – does not get to pick and choose the laws he likes, and the laws he doesn’t. He is an elected public servant, not an emperor. If he refuses to implement or uphold this law, then he is breaking the law. If he refuses to certify the election, then he’s in violation of the state constitution.

Dereliction of duty is no defense. This is not some game. If he refuses to follow the law, then he would be unilaterally and illegally blocking something like 80,000 people from accessing the health care that a massive majority of Maine people approved for them yesterday. That is unacceptable, and would be – say it with me again – illegal.

Now, let’s talk about funding. The Governor (and some legislators) have already started saying that this is going to cost the state hundreds of millions of dollars (lie) and that they won’t implement it without funding.

First of all, here’s the absolute truth about the cost. In 2018, the Maine Legislature’s Office of Fiscal and Program Review estimated the state cost to be $14 million. That’s it. Not the terrifying numbers (lies) the Governor is throwing out.

In future years, it costs more, true, but let’s also remember that – at its most expensive – the feds are going to be footing 90% of the bill for this. 90%. We put in a dollar and get $9 back.

And I say “back” very specifically. Opponents like to say that the federal money we get for this isn’t “free”, it still costs us in taxes. That’s absolutely true, and the reason that argument has always struck me as completely ridiculous is that we are paying those taxes in no matter what. Our federal taxes have not been lower because we did not do Medicaid expansion, and our federal taxes are not going to go up now that we’ve passed it. The difference is that we are going to recover those tax dollars back to Maine to invest in our people, our hospitals, and our economy, rather than keeping them parked in DC.

Now, the ballot question that passed did not contain a funding mechanism (FYI, a ballot initiative can’t initiate an appropriation of funds, as I understand it: I believe that, in Maine’s constitution, that power is reserved exclusively for our House of Representatives). So now, the Governor and some legislators seem to be saying, we have to find a funding source, and if we don’t we won’t implement.

Wrong again.

If the Legislature and the Governor do not specify a funding source, you know what happens? It takes effect anyway. The state will have to accrue payments for our share next year, and either cover it through a supplemental budget amendment or some other means. There is absolutely no way that the Governor gets to spike this over a funding question, and the Legislature does not have to do anything about funding before it can take effect. It’s coming. It’s done.

OK, technically, the Legislature could repeal it. That is not going to happen. Even after all of the brouhaha this year over last year’s ballot questions, it would take a majority in both the House and Senate to kill this, and given that both chambers have passed expansion repeatedly, there’s no vote math I can envision where that happens.

By the by, the Governor’s bellicose statement this morning went back to that exact same playbook I mentioned up above, ranting (and lying) that funding this bill would mean taking care and coverage away from “the elderly and the physically disabled”.

Even ignoring for a moment, Governor, that you’ve taken serious and repeated swings at those populations too over and over and over again during your time in office (so methinks these may be crocodile tears), it’s maybe worth remembering that you and your allies tried this exact line of attack during the campaign and got clobbered 60-40. I don’t think Mainers are buying what you’re selling anymore.

 

Would you like to know more?

Here’s a great report on expansion in Maine. If you’re looking for facts, this is a good go-to resource for you.

 

Until next time, friends, I remain,

-Steve

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