Daugaard asks for approval to partially expand Medicaid (updated)

Gov. Dennis Daugaard wants to expand Medicaid in South Dakota under the Affordable Care Act — but only part of the way, and only if the federal government lets him, which some experts say is unlikely.

Daugaard, with support from legislative leaders in both parties, has sent a letter to federal Health and Human Services Secretary Kathleen Sebelius asking for permission to cover people earning up to 100 percent of the poverty line in the Medicaid program. The health care law calls for states to expand Medicaid up to 133 percent of the poverty line, and foot most to all of the bill.

"The one-size-fits-all approach that’s offered by the Affordable Care Act really doesn’t match up with the beliefs of most South Dakotans that we want to help those who can’t help themselves, and those who can help themselves should," Daugaard said Friday.

If Daugaard gets his way, people earning up to 100 percent of the poverty line — $11,670 for a single adult or $23,850 for a family of four — would be eligible to enroll in Medicaid.

People earning between 100 percent and 133 percent of the poverty line could — as they can now — buy health insurance on the Affordable Care Act’s online exchanges and receive substantial subsidies to offset those costs.

Last year, Daugaard asked Sebelius informally if she would approve such a solution, and was told no. But he believes that with other states getting waivers to pursue alternative Medicaid expansion approaches, the answer might be different this time.

"This is a dynamic situation," Daugaard said Friday. "I think the federal government may be more open to considering things like that. Certainly I want to keep that conversation going."

Under the Affordable Care Act, the federal government promises to pay almost the entire cost of Medicaid expansion for the first several years for states that do so, then 90 percent or more of it into the future.

Robin Rudowitz, associate director for the Kaiser Commission on Medicaid and the Uninsured, said the federal Centers for Medicare and Medicaid Services have warned states away from partial expansions.

"CMS has issued guidance related to waivers, and what waivers might be eligible for the 100 percent (federal) matching funds," Rudowitz said. "Their guidance is that these partial expansions would not be eligible for the 100 percent matching funds."

Wisconsin, in fact, just recently pursued a Medicaid expansion up to 100 percent of the poverty line, leaving those over the poverty line to join the exchanges. But the federal government isn’t paying the full cost of the expansion, as it is for states that went the whole way. Instead, that expansion happened under the normal Medicaid formula, where the federal government pays for just over half the cost.

Other states with waivers, such as Arkansas and Iowa, agreed to provide health care coverage up to 133 percent of the poverty line. They received flexibility to provide that care in other ways, using Medicaid money to instead support their residents’ private insurance on the exchanges.

Nationally, 25 states and Washington, D.C., have expanded Medicaid. Several others are considering it.

If Daugaard receives a swift response, he said he’s willing to amend his proposed 2015 budget to include Medicaid expansion for next year.

Democrats in the Legislature have long urged Daugaard to expand Medicaid. They say the low-income uninsured need health coverage, and that the federal funding would bring hundreds of millions of dollars into the state’s economy.

House Democratic leader Bernie Hunhoff, D-Yankton, said he believes a full expansion is the best course but is willing to support a partial expansion.

"Anything we can get on the table is a good step forward," Hunhoff said. "Politics is the art of the possible… I don’t think a partial expansion should limit us from continuing to pursue full expansion down the road."

Daugaard, along with most Republican lawmakers, has resisted expansion. The governor has worried the federal government could renege on its promise to pay most of the cost. And he says he doesn’t want to create more people dependent on government aid than is necessary.

But Daugaard has never ruled out Medicaid expansion, saying he just wants to be cautious.

Senate Republican leader Tim Rave, R-Baltic, said he sees a partial expansion as a good, practical approach.

"Members of leadership in the Republican side have been talking at length about how we could find a common-sense, conservative approach to Medicaid expansion," Rave said Friday. "I believe that we’ve come up with a fairly good approach and are looking forward to that discussion."

Outside groups that have been pushing for Medicaid expansion say they’re happy to see Daugaard’s letter but are uncertain about its chances for success.

"We would be supportive of any programs that have a credible chance of being accepted by the federal government," said Dave Hewett, president and CEO of the South Dakota Association of Healthcare Organizations. "The ability to have a budget that allows for the state to move forward sooner rather than later on expansion is a good thing."

Poll: South Dakotans split shutdown blame on party lines

A new poll from the Democratic-affiliated Nielson Brothers Polling found a sharply divided state over the ongoing government shutdown.

Overall, the poll found 38 percent of voters blame primarily Republicans, 35 percent blame primarily Democrats, and 24 percent see both equally culpable.

But NBP found voters far more likely to blame ideological opponents for the stalemate. Around 66 percent of Democrats blame Republicans, while 13 percent blame their own party. Among Republicans, 55 percent blame Democrats and 16 percent say it’s the GOP.

Ideologically, 78 percent of liberals blame Republicans, while 73 percent of people who identify with the tea party blame Democrats. 

Among conservatives who didn’t identify with the tea party, 55 percent blamed Democrats and 16 percent pointed the finger at the GOP. Independents were more likely to see the Republicans as responsible, with 47 percent blaming the GOP vs. 17 percent Democrats.

NBP also asked voters their opinion of the Affordable Care Act. A majority, 54 percent, oppose the act, while 36 percent support. This, too, follows party lines: support for the law was 62 percent among Democrats and 15 percent among Republicans.

The automated poll was conducted form Oct. 2 to Oct. 6, with just over 800 respondents. The margin of error is about 3.45 percent.

Today’s release did not include all the questions asked in the poll, or full crosstabs. NBP says they’ll release more findings in the near future, including questions about the U.S. Senate race. 

Noem: Fight Obamacare, but maybe not to the bitter end

In my story this morning, Rep. Kristi Noem defended the decision by the Republican-controlled House of Representatives to attach language defunding the Affordable Care Act to a must-pass funding bill — but unlike some conservatives didn’t promise to refuse to vote for a funding bill that contains funding for the ACA.

“I’m hopeful that they will choose to defund Obamacare in the provision that comes back, recognizing how detrimental that bill is to so many families in South Dakota, but if they choose not to, I’ll have to look at the bill and see what kind of spending reductions it has in it, and see if I can support it,” Noem said Monday.

That’s important given the most likely turn of events in the coming week. The House passed a government funding bill (a “continuing resolution,” or “CR”) with the defunding attached. The Democrat-controlled Senate is expected to overcome a filibuster by Sen. Ted Cruz  (UPDATE: a reader tells me that Cruz’s filibuster-esque speech may not actually technically be a filibuster because it’s not delaying a vote — the Senate can’t even vote on cloture until tomorrow) and strip the defunding clause out of the CR. That would send the CR back to the House, which would have a choice: accept the fait accompli and pass a final CR that doesn’t defund the Affordable Care Act, or hold its ground and refuse to fund the government if the ACA is also funded.

The latter is the route that results in a government shutdown, because Democrats and President Barack Obama are expected to be even more unyielding, refusing to countenance the destruction of their signature policy victory of the past five years.

Noem didn’t say which way she’d fall, but her response suggests she’s open to the former path.

Thune calls for Republicans to pick their battles wisely vs. ACA

Stace Nelson got all the attention, but don’t miss my report inside today’s paper on Sen. John Thune’s statements about the Affordable Care Act.

Thune got a lot of press for joining conservative bomb-throwers Mike Lee, Ted Cruz and Marco Rubio in supporting a bill to defund the controversial health care law. Other GOP senators, unusually, criticized the effort in explicit terms as “silly,” a “feckless” and “a non-starter.”

So I was surprised to talk to Thune and find his emphasis to be more cautious than militant. Defunding the entire law was “one approach” that was unlikely to succeed, Thune said; instead, he urged targeted “rifle shots” aimed at identifying the least popular parts of the law and getting Democrats to join Republicans in repealing or defunding them.

He didn’t repudiate the effort to defund the whole law, but did say that “I don’t think anybody thinks shutting the government down is a good solution.” Still, his call for Republicans to pick their battles wisely didn’t include any of the brusque dismissals of the defunding effort that raised so much conservative outrage when made by people like John McCain and Bob Corker.

Here’s the story:

Congressional Republicans “have to pick our battles wisely” as they try to impede the Patient Protection and Affordable Care Act, Republican Sen. John Thune said Tuesday.

Thune has signed on to a bill that would block funding for the controversial health care law, but acknowledges that’s unlikely to pass with Democrats controlling the Senate and presidency.

So he’s urging his colleagues to pursue targeted “rifle shots” aimed at less popular parts of the bill, where they might be able to persuade some Democrats to come on board.

"Since the president has already agreed to delay the employer mandate, just say that no funds shall be expended to enforce the employer mandate," Thune said. "Or say that no funds shall be expended for the Internal Revenue Service to enforce the individual mandate. I think you have to find things that are perhaps doable, where you might have bipartisan support."

The employer mandate is a provision requiring large employers to provide health insurance to their workers. President Barack Obama delayed that for at least one year. The individual mandate is a requirement that everyone get health insurance or pay a tax penalty.

Even as conservatives “believe profoundly that Obamacare is the wrong prescription for the country and will be very harmful to people and the economy,” Thune said Republicans need to be “realistic” about what they can accomplish.

Sen. Tim Johnson, a Democrat, disagrees with Thune’s criticism of the Affordable Care Act.

"The Affordable Care Act is already helping tens of thousands of South Dakotans get better health insurance coverage, and before it became law we were the only industrialized country in the world without a national health care strategy," Johnson said in a statement. "Trying to repeal this law would only create more obstruction in an already divisive Congress. Continuing to implement the health care law will further expand health insurance to the uninsured, self-insured, and many others who currently cannot get it or afford it."

A battle is brewing over funding the Affordable Care Act that could result in a government shut down. Many Republicans say they won’t vote for any bill funding the government if it contains funds to implement the health care law. But if the Republican-controlled House refuses to pass a spending bill with ACA funding, and the Democrat-controlled Senate refuses to pass a spending bill without ACA funding, the result could be no spending bill at all — and thus, no government until the impasse is resolved.

"I don’t think anybody thinks shutting the government down is a good solution," Thune said. "Most people realize that to achieve our ultimate goal, which is to make sure Obamacare never gets implemented, we’ve got to be in a position to fight, and we have to pick our battles wisely. I think you’ll see a fairly robust discussion about that this fall when we get back."

What do the GOP candidates want instead of the Affordable Care Act?

Annette Bosworth, Larry Rhoden and Mike Rounds all want to repeal the Affordable Care Act.

What would they do instead?

Bosworth tossed out a few ideas, including more transparency, more skin in the game for patients, and cutting non-health-care spending to help fund care for those who can’t afford it.

But she said she’s not ready to present a more comprehensive version of health care reform yet.

"I have had several discussions and lots of fantastic thought leaders that I’ve continued to share my ideas with, but sharing them at this stage is — I’ll continuie to be able to tell that as this campaign unfolds," Bosworth said.

Former Gov. Mike Rounds said he’d support a new comprehensive health care reform with a much smaller role for the federal government to replace the ACA.

"As long as you didn’t rub (Democrats’) nose in it, I think there would be a possibility of using an alternative that actually used the market system itself, that allowed providers direct access once again without government intervention, and that reduced the actual cost to the federal taxpayer," Rounds said.

Rhoden wants to enact tort reform to stop “frivolous” lawsuits against doctors, expand health savings accounts, and allow insurance companies to compete across state lines. The last, Rhoden said, would increase competition and thus lower costs.

That’s a popular idea on the right, being espoused by people including Sen. John Thune. Rounds, interestingly, has been opposed to this idea for years. He believes letting companies compete in other states would gut the system of state insurance regulation he believes works quite well.

He also said it would destroy the cost advantages states like South Dakota have now, as supply and demand worked on insurance rates to drive up demand for low-rate states.

"If you have everyone in New Jersey buying their program under South Dakota rates… I’m pretty sure we wouldn’t have competitive rates, we would have New Jersey rates," Rounds said.

Rick Weiland, the only Democratic candidate running for Senate, is generally a supporter of the Affordable Care Act and doesn’t want to repeal it. But he does want to change it, chiefly to add a “public option” — a choice for people buying private insurance to also buy into the Medicare program, if they want.

Bosworth and the doctors

In this morning’s paper, I reported on how Republican U.S. Senate candidate is focusing on her medical background as she runs against two rivals with more political experience.

The story was introduced by an event Bosworth held this past week, where she invited a dozen local doctors over to her medical office to discuss the Patient Protection and Affordable Care Act. But ironically, there wasn’t enough room in the paper to actually describe what happened at that meeting.

Every one of the doctors at the meeting was against the Affordable Care Act. Some, like Dr. Paul Amundson, the chief medical officer for Dakotacare (which is participating in the ACA’s exchanges), had fairly nuanced takes, arguing the confrontational law was simply poorly conceived and would be counter-productive.

"That’s one of the fallacies of the Affordable Care Act… as we all know, you’ve got to have a lot of healthy people paying in money to pay for the people who cost a lot of money — in general the older people," Amundson said.

He noted that young people on the individual market might pay 50 percent more for their insurance before government subsidies, while the story was different for older people.

"Take DakotaCare for example — a lot of our individual members are in their 60s… those people, their rates will go down, significantly, but somebody’s got to pay for it," Amundson said. "I don’t think there’s going to be that many young, healhy people adults who are going to jump on (to balance that)."

Other doctors present were fiercer in their opposition to the law.

"In this mechanism that’s involved with the ACA… we no longer have the control," said Dr. David Auch, an internist at the Veterans Affairs hospital in Sioux Falls. "We no longer have the ability to say this is good, this is bad, this is not."

Other attendees at Bosworth’s meeting painted darker pictures.

"The goal is to federalize medical care, and eventually end up in a single-payer system, or just frankly a socialist government-run system," said Dr. John Oliphant, a plastic surgeon. "They want to abolish private medicine altogether."

On that point, Bosworth agreed. “It will be,” she said.

But she said she was most impressed with the arguments made by Dr. Oleg Georgiev, a doctor who defected from communist-controlled Bulgaria in 1984. Georgiev said the Affordable Care Act reminded him of what he had seen growing up.

"This is collectivism, communism, socialism, fascism — call it whatever you want to call it. I’m from a communist country, I know how the system is," Georgiev said.

"Physicians who’ve seen other programs, and that have been a part of this… have the more engaged answers because they’ve been through these lessons," Bosworth said after her roundtable finished.

Though the dozen doctors gathered at Bosworth’s event varied only in the intensity of their opposition to the Affordable Care Act, the wider medical community has a much broader range of opinions on the controversial law.

The South Dakota State Medical Association’s official position is that the Affordable Care Act is a mixed bag but with “more positive than negative,” said SDSMA president Dr. Daniel Heinemann.

"Physicians have long known, and we’ve been telling anyone who listens to us, that…  people who have health coverage live longer and live healthier. Anything we can do to increase that is a positive," he said. 

But “we’re finding little things that were unintended consequences that need to be reviewed,” Heinemann said, pointing to its formula for paying physicians and its Independent Payment Advisory Board.

Some South Dakota doctors passionately support the Affordable Care Act, while others see it as a catastrophe. Plenty more are in between.

"When you look at things like the Affordable Care Act, it comes down to political ideologies for physicians, just like it does for everybody," Heinemann said.

Bosworth said she hosted the meeting, which was promoted by her Senate campaign, in part to foster a public discussion in the medical community about the Affordable Care Act.

"You’ve got every other news program saying, defund Obamacare. Where are the discussions in my community?" Bosworth said. "If not me to lead it, then who would? And what would their agendas be? When you get the discussions led by… insurance companies, led by private citizens, led by physicians, led by hospitals, each one of them has an agenda. What if you just bring them together and say, ‘Let’s talk about this.’"

She said hearing the doctors criticize the Affordable Care Act Tuesday night reinforced her beliefs about the law.

"The better question is, will what I’ve learned change my thoughts? The answer is no," Bosworth said. "I heard in a public forum what I’ve been hearing from one physician at a time, which is, the closer they are to seeing what this law unfolds, the less they see it improving the health of the patients in front of them."

Weiland endorses universal ‘Medicare for all’

Via Cory Heidelberger, I see that Democratic U.S. Senate candidate Rick Weiland made some minor news yesterday when he said his ideal health care plan was not the Patient Protection and Affordable Care Act (which I believe he supports), but universal Medicare:

On Obamacare, Weiland said he is concerned with the amount of input large health care companies had on the legislation. Every citizen should be given the opportunity to buy into Medicare if they want, he said.

Read the Mitchell Daily Republic’s story here.

The article doesn’t go into any more detail on Weiland’s stance, so it’s unclear whether he was speaking abstractly about his ideal policy, or talking about something he’ll push for if elected.

UPDATE: Weiland leaves a comment on this post, clarifying his position:

We have to deal with health care reality, not what might have been, and the reality today is that “universal medicare for all” is just not in the cards.

What I propose is not universal Medicare for all, it is simply that any citizen who so chooses be entitled to buy into Medicare at a fair market price (a price that absolutely guarantees no current Medicare recipient can be adversely affected).

This is the so called “single payer option” that could have helped keep the insurance industry honest, but that was driven out of the Affordable Care Act to the great detriment of, and at great cost to, the American public.

Read his full comment below.

Universal Medicare as a health care proposal is not a new idea. In fact, none other than George McGovern advocated that back in 2009:

But what seems missing in the current battle is a single proposal that everyone can understand and that does not lend itself to demagoguery. If we want comprehensive health care for all our citizens, we can achieve it with a single sentence: Congress hereby extends Medicare to all Americans.

Meanwhile, one of the most vocal proponents of the Affordable Care Act’s intricate balance of reforms was Tom Daschle — Weiland’s former boss and political ally.

Interesting connections all around.

Rounds decides against ACA-de-funding battle

In my story this morning on the U.S. Senate race, Mike Rounds was undecided on a brewing battle about funding the Affordable Care Act. Some conservatives want to de-fund the health care law — and are threatening to shut down the government if a new spending bill is passed with ACA funding included. Because of Democratic control of the Senate and President Barack Obama’s veto power, most experts on all sides say it’s highly unlikely Republicans would actually be able to win and de-fund the law.

In our interview last week, Rounds said he didn’t know enough about the issue:

On the subject of de-funding the Affordable Care Act, and possibly risking a government shutdown, Rounds said he didn’t know the exact details of the proposal.

"If there was a way to get the Obamacare off the backs of the American public, it would be a fight worth having," Rounds said. "I would want to assess whether or not there was any possibility of success in getting it done, or if there was any possibility of coming up with the votes to have an impact."

Larry Rhoden and Annette Bosworth, Rounds’ two GOP rivals, both endorsed an all-out fight over the ACA.

But today, Rounds announced via his Twitter account he was against wasting time on what he called a “symbolic vote” due to de-fund the health care law:

It’s another case where Rounds and his opponents say they have the same policy goals but differ on the best means to accomplish that.

Bosworth’s Medicaid testimony

Potential U.S. Senate candidate Annette Bosworth made an appearance at yesterday’s Medicaid expansion hearing. Bosworth, a physician, testified against Medicaid expansion, though in nuanced terms.

In her testimony, Bosworth stuck to the theme of innovation that she highlighted when announcing her potential campaign. “There are times when an industry reaches a critical point where you change things,” Bosworth said near the start of her remarks.

She called the emotional pro-expansion testimony earlier in the hearing evidence of “palpable stress that our system needs to change” and said she “does not envy (the task force’s) position” in having to make the choice about expansion.

But Bosworth said Medicaid expansion was faulty because it just perpetuated the current system rather than promoting innovation.

"In this federal money there is no budget for (innovation)," Bosworth said. "It is simply to mandate the same broken system Medicaid has been offering us for years."

As an example, Bosworth talked about her work with people in shelters, for whom Medicaid would cover emergency care but not the social worker to implement cost-saving lifestyle changes.

"I would encourage you to not accept these federal dollars," she concluded.

Hospital contribution to Medicaid expansion on the table

If South Dakota expands Medicaid to provide health coverage tens of thousands of low-income citizens, should hospitals have to pay part of the bill?

Some state officials have put that idea on the table, but a representative of the state’s hospitals tried to head off such a proposal Tuesday.

Speaking at a task force studying Medicaid expansion, Dave Hewett of the South Dakota Association of Healthcare Organizations said hospitals were already helping to pay for Medicaid expansion under a national deal made before the Patient Protection and Affordable Care Act passed in 2009.

"Early on with the (Patient Protection and Affordable Care Act), many, many dollars were taken away from providers to pay for expansion," Hewett said. "We’ve already given, and we’ve given substantially."

South Dakota hospitals, he said, will pay $15 million next year as part of a deal to pass the Affordable Care Act — and more than $30 million in future years. Hewett calculated that hospitals would save around $30 million in uncompensated care if Medicaid eligibility were raised to 138 percent of the federal poverty line.

Before Monday’s hearing, a senior adviser to Gov. Dennis Daugaard said the question of hospital payments was an important discussion point.

"The providers, and by that I mean primarily the hospitals, should benefit from this because it will reduce their charity care," said Deb Bowman, the chair of Daugaard’s Medicaid task force. "So should we ask that providers have some skin in the game here besides their Medicaid rate?"

Hewett said his group would be opposed to hospitals paying more as part of a Medicaid expansion bill. But he wasn’t sure if that position would hold if it were the only way to get an expansion deal done.

"We’d have to cross that bridge when we came to it," Hewett said.

Medicaid expansion is provided for by the Affordable Care Act. Currently in South Dakota, only the elderly, the disabled, children and pregnant mothers qualify for Medicaid support. If the state expands Medicaid, then an estimated 48,000 low-income adults could become eligible for the government health insurance system.

The state’s hospitals and other medical providers are strong proponents of expanding Medicaid, saying it will benefit both the state and control their expenses. Leaders with both the Avera and Sanford health systems testified in favor of expansion Tuesday.

Others of the nearly 20 members of the public to testify Tuesday gave personal anecdotes to support Medicaid expansion. Cindy Franklin of Flandreau told about how she was diagnosed with cancer while uninsured.

"Unable to pay, I had to rely completely on the goodwill of the cancer center to cover the costs of my lifesaving treatment," Franklin said. "Cost shouldn’t be a determining factor in whether someone or not someone beats cancer and remains cancer-free."

But plenty of citizens argued against expanding Medicaid, too. Some cited the cost to the federal government, which would amount to around $2 billion over the next ten years just for South Dakota if the state expanded eligibility.

"I believe the federal government will become even more unreliable as a funding source," said Jim Holiway of Sioux Falls. "Now is not the time to expand government, which the Medicaid expansion is."

Others said they were open to the government taking steps to help the uninsured, but that Medicaid was the wrong way to go about it.

State Rep. Leslie Heinemann, R-Flandreau and a practicing dentist, said Medicaid’s reimbursement rates for medical professionals are so low it often doesn’t cover costs.

"Why should the feds give that group (of roughly 48,000) a second-class system of care?" Heineman said.

But he suggested he could support a compromise approach that several other states are exploring for their own Medicaid expansions. Iowa and Arkansas are seeking waivers from the federal government to put some of their low-income workers not into Medicaid but into the Affordable Care Act’s health insurance exchanges.

While Medicaid is a government-run program, the exchanges let low-income individuals buy subsidized care from private insurance companies.

It’s also more expensive to the government than Medicaid, with Bowman saying one estimate is that a Medicaid patient will cost around $6,000 per year to cover while a patient on the exchange will cost around $9,000.

Those other states also haven’t yet received final approval from the federal government to pursue their alternatives, with many details left undecided.

But Daugaard’s Medicaid task force is taking a careful look at those alternative proposals, as well as the question of whether hospitals should pay part of the bill, as it develops a report on the subject that’s expected to be finalized late this summer. 

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