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KS Democrats mull new plan for Medicaid, marijuana reform

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[ MM Curator Summary]: Kansas may expand Medicaid and let Kansas toke up without fear this year.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.



KANSAS CITY, Mo. — Unable to maneuver through gridlock in the Kansas Legislature, Kansas House minority leaders will introduce constitutional amendments in hopes of putting the issues of Medicaid expansion and marijuana legalization to a statewide vote.

“Some people might think it’s kind of drastic to do a constitutional amendment, and it is,” Assistant House Democratic Leader Jason Probst said. “But the reason is that we’ve just had an absolute blockade.”

Voters in Missouri, Nebraska and Oklahoma have passed Medicaid expansion in recent years, but Republicans in Kansas have refused to even debate the issue in the legislature.

“We know that Kansas wants this,” Probst, who represents Hutchinson, said. “We know that they’ve wanted it for a long time. We have a lot of data that shows overwhelming support for it. Our rural hospitals have been screaming for it.

“We could have really used it during the pandemic, when a lot of people needed more health care and couldn’t afford it. The legislature and the Republican leadership has actively blocked it at every turn. I think it’s time to start turning these things over to Kansans and letting them decide.”

House Democratic Leader Tom Sawyer said Medicaid expansion would “provide about $1 billion” annually to Kansas.

“All of our surrounding states have Medicaid expansion,” Sawyer, who represents the Wichita area, said. “I think it’s time the voters have their say on it.”

It’s a similar story for marijuana reform.

Missouri and Oklahoma voters have passed medical marijuana laws, while the drug is legal in Colorado and has been decriminalized in Nebraska.

That leaves Kansas with some of the most strict marijuana laws in the U.S. despite growing public sentiment in favor of legalization.

“In my district, it’s been the No. 1 issue for about six or seven years now,” Sawyer said.

The Kansas House passed a medical marijuana bill in 2021, though it still prohibited smoking and vaping of marijuana, but it never gained traction in the Kansas Senate nor made it to Gov. Laura Kelly’s desk.

“I’m eager for people in Kansas to enjoy the same benefits that people have in other states,” Probst said. “We are an island. We are surrounded by states that provide for their residents the things that they want. Kansas, and the leadership in this building, has decided they know better than Kansans what they should have.”

House Democrats plan to continue to pursue more traditional legislative options for expanding Medicaid and legalizing marijuana, for both medical and recreational use, in Kansas, but the constitutional amendment path may offer new hope to move the issues forward.

The hope is that Republicans who have been reticent to buck party leadership and support Medicaid expansion or marijuana reform might be more willing to support giving the people of the state they represent the chance to weigh in on the issue.

The Democrats’ proposed amendments would not spell out any new policy, but it would make Medicaid expansion and/or marijuana reform a constitutional requirement, compelling legislative action on the issues.

If passed, voters in Kansas could have a chance to decide Medicaid expansion or marijuana legalization for themselves during the November general election.

Sawyer said it’s also possible the issue could be certified for the Aug. 2 primary, when an anti-abortion amendment already is scheduled for a vote.

“Certainly politically, it would make more sense or be more strategic to put it on the August primary,” Probst said.


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California Would Expand Medicaid to People in U.S. Illegally Under Gavin Newsom Proposal

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[ MM Curator Summary]: CA continues to add coverage for non-citizens.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.


Democratic governor says California should be first state to offer healthcare to all residents regardless of immigration status


California Democratic Gov. Gavin Newsom unveiled his proposed 2022-2023 state budget in Sacramento on Monday.

Photo: Rich Pedroncelli/Associated Press

California would become the first state to provide access to its Medicaid program to all low-income residents, regardless of immigration status, under a proposal unveiled Monday by Gov. Gavin Newsom.

The plan is part of a $286.4 billion budget plan the Democrat has proposed that also includes billions of dollars in investments for the state’s wildfire response, homelessness and drought assistance.

If the plan is approved by state legislators later this year, Mr. Newsom said, all low-income Californians would qualify for the state’s Medicaid program, known as Medi-Cal, starting January 2024.

California previously extended health coverage to children who entered the U.S. without legal authorization in 2016 and later expanded those benefits to young adults up to the age of 26. Last year, California became the first state in the nation to allow seniors aged 50 and over who aren’t citizens or legal residents to participate in the program.

Once fully implemented, the Medi-Cal expansion is expected to cost about $2.2 billion a year, Mr. Newsom said. The proposed spending is possible in part due to a $45.7 billion state budget surplus that is projected for the fiscal year that begins in July, due in part to growing receipts from high-income earners who pay a large share of state income and capital-gains taxes.

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“I’m confident that we can do that within the constraints of the budget,” Mr. Newsom said, when asked whether the outlays would be sustainable at a press conference on his budget proposal.

Angelica Salas, executive director of the Coalition for Human Immigrant Rights, an advocacy group, said the expansion is especially important at a time when the Covid-19 pandemic has disproportionately affected low-income immigrant communities.



Marie Waldron, leader of the State Assembly’s Republican minority, opposes the expansion because she says Medi-Cal is already failing to adequately serve the approximately 14 million people who currently use the program in a state with a population of 40 million. “Enrolling millions more into the system will do little but give people an expensive insurance card that doesn’t get them access to quality healthcare,” she said.

Republicans unsuccessfully opposed last year’s law that expanded Medi-Cal to senior citizens who entered the U.S. illegally.

Some Democrats, who have a large majority in both houses of California’s Legislature, have previously proposed expanding Medi-Cal to all residents regardless of immigration status. With Mr. Newsom’s support, the proposal now has a good chance of passing into law.

Some Democratic lawmakers are pushing for a statewide single payer healthcare system. They recently released a framework that would rely on new taxes on businesses, payroll and personal incomes for all but the lowest-income individuals.

Mr. Newsom declined to comment on that proposal Monday.

Write to Christine Mai-Duc at


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GA- Reform- CMS Reverses Approval of Work Requirements and Premiums for Georgia Medicaid

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[ MM Curator Summary]: GA’s planned Medicaid expansion has been stopped by CMS.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.



On December 23, 2021, CMS announced that it was rescinding its prior approval of the Georgia Pathways to Coverage demonstration project, which would have required Georgia residents to work as a condition of Medicaid eligibility and allowed the state to charge premiums to a larger class of individuals than permitted under the Medicaid statute. These proposals could have gone into effect as early as next week had CMS not withdrawn its prior approval.

The Georgia Pathways to Coverage demonstration project would have required adults within a certain percentage of the federal poverty level to work at least 80 hours each month to qualify for Medicaid. In addition, the demonstration would have required Medicaid beneficiaries earning between 50 and 100 percent of the federal poverty level to pay monthly premiums.

CMS approved the demonstration project on October 15, 2020. According to the Kaiser Foundation, Georgia was one of eleven states that received approval to impose work requirements under the Trump Administration.
In his first week in office, President Biden signed an executive order directing CMS to review Medicaid work requirements that were approved under the previous administration. Soon thereafter, by letter dated February 12, 2021, CMS informed Georgia Medicaid that it was considering withdrawing its approval of the Georgia Pathways to Coverage demonstration, citing “ongoing disruptions caused by the COVID-19 pandemic.” Georgia agreed to delay implementation of its demonstration project until the end of 2021 while it negotiated with CMS to address the agency’s concerns.

Last week, CMS informed Georgia that it was reversing its prior approval of the Georgia Pathways to Coverage demonstration project. The agency explained that both the work and the premium requirements contained in the demonstration project would restrict Georgian’s access to coverage.

None of the other ten states that received approval from the Trump administration to impose work requirements have done so. Earlier this year, CMS rescinded its past approval of work requirements for South Carolina, Ohio, Wisconsin, Arizona, Indiana, and Utah. And federal courts have blocked the implementation of work requirements in Arkansas, Kentucky, Michigan and New Hampshire.

A copy of the December 23, 2021 CMS letter rescinding its prior approval of the Georgia Pathways to Coverage demonstration project is available here. A CMS press release announcing its decision to rescind its approval of the demonstration project is available here.


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AR- Premiums for Arkansas Medicaid expansion must end in one year

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[ MM Curator Summary]: CMS is now forbidding premiums for expansion members.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.



In June 2018, when Arkansas became the first state in the nation to implement work requirements for certain Medicaid beneficiaries, Governor Hutchinson was triumphant.

“We’ve wanted to establish a work requirement … for a long time,” he said at the time. The Obama administration had refused to authorize work requirements, but the Trump administration gave the green light. “With this development, Arkansas has become a national leader in rethinking the delivery of public assistance,” the governor boasted.

Three and a half years later, the work requirements are gone. The state did not even ask to continue the policy after the Biden administration signaled early in 2021 that it would no longer allow Medicaid work requirements. The Biden administration officially revoked the state’s authorization in March; by that point, the policy had already been blocked for two years by a federal judge.

Last week, the Biden administration established another red line. On Dec. 21, the federal government approved a proposal from Arkansas officials to continue the state’s unique version of the Medicaid expansion program, but the feds rejected Arkansas’s request to continue imposing monthly premiums on certain beneficiaries. The premiums will be allowed to continue for one more year before ending on December 31, 2022.

The Medicaid expansion, authorized by the federal Affordable Care Act, covers adults aged 19-64 who make less than 138% of the federal poverty level (an annual income of $17,774 for an individual or $36,570 for a family of four). Ideological opposition to Obamacare has led to fierce debates in red states over whether to expand Medicaid, and a dozen states still have not done so. Some Republican governors, like Hutchinson, have been willing to take the federal money for coverage expansion — but have sought to bend the program in various ways, including imposing requirements on beneficiaries that critics allege create barriers to coverage and reduce the number of people enrolled.

Federal law allows states to experiment with new policies that deviate from Medicaid rules under agreements known as waivers, but such programs require federal approval. In an executive order last January, the Biden administration announced it would review Medicaid waiver policies “that may reduce coverage under or otherwise undermine Medicaid or the ACA.”

Work requirements were the first shoe to drop. Now, the Biden administration has made clear it will not allow premiums to be imposed on beneficiaries in the Medicaid expansion population, nixing proposals to continue premiums from both Arkansas and Montana on Dec. 21. In both cases, the Biden administration gave a one-year off ramp before premiums will end.

Three other states currently have waivers for Medicaid expansion premiums, according to tracking by the Kaiser Family Foundation. (Another such waiver is pending, and another has been currently set aside by a court ruling.) Presumably, the Biden administration will not renew such provisions or allow new requests for premiums from other states.

The novel version of the Medicaid expansion program in Arkansas, first enacted in 2014, uses Medicaid funds to purchase private health insurance plans on the Arkansas Health Insurance Marketplace — the regulated marketplace created by the ACA — to cover most beneficiaries. Once nicknamed the “private option” and now known as “Arkansas Works,” it has been implemented under a series of waiver agreements with the federal government.

The “Arkansas Works” waiver expires at the end of this year. Arkansas’s request for a new waiver, submitted last summer, renamed the program ARHOME and outlined new changes and policy initiatives.

Despite the rejection of the state’s request on premiums, Governor Hutchinson described the feds’ overall approval of ARHOME as “good news” in a press conference on Dec. 21. “This will allow 300,000 low-income Arkansans to continue to receive health care,” Hutchinson said.

The governor said the Biden administration’s decision against allowing premiums in ARHOME was “not unexpected,” despite the state’s efforts to convince federal regulators otherwise. “We continue to believe it is important for nonelderly, nondisabled adults to contribute to the cost of their coverage,” Hutchinson said in an email this week.

The governor noted that beneficiaries still may incur some costs even after premiums are phased out. Small co-pays are allowed under Medicaid rules, with certain limitations. (Premiums are monthly payments made at a set rate, whereas co-pays are assessed when a medical service is actually used.)

Arkansas Works currently charges co-pays to most beneficiaries who make more than the federal poverty line. The state’s ARHOME waiver request proposed allowing co-pays to be charged to some beneficiaries with lower incomes (down to 21% of the federal poverty level) and raising the caps on the total quarterly amounts that can be charged to those at higher incomes, among other changes. State officials hope to implement the updated co-pays — which will follow normal Medicaid rules — this year, pending approval from the state legislature and the Biden administration. 

Arkansas had received permission for premiums under its previous waiver agreement, which was approved by the Obama administration. (After Trump took office, the waiver was amended to include work requirements, approved in 2018.) But the Centers for Medicare and Medicaid Services (CMS), the federal agency overseeing Medicaid, “has since determined that premiums can present a barrier to coverage,” according to a letter CMS Administrator Chiquita Brooks-LaSure sent to the state last week.

Premiums for Medicaid expansion beneficiaries “are not likely to promote the objectives of Medicaid,” Brooks-LaSure wrote in the letter, which accompanied the federal approval for ARHOME.

Joan Alker, the executive director of Georgetown University’s Center for Children and Families, said that CMS made the right decision.

“For low-income populations, it’s very clear that premiums reduce participation,” Alker said. “There’s lots of research to back this up: When premiums are imposed, enrollment goes down. In our system having insurance is the price of admission, so we’re just kicking people out of the system.”

Currently, the state imposes $13 per month premiums on most beneficiaries who make more than the federal poverty line ($12,880 for an individual or $26,500 for a family of four). Beneficiaries do not lose coverage for failure to pay, but incur a debt to the state, which can be withheld from state tax refunds.

Alker said premiums can still be a barrier to coverage even if the state doesn’t kick people off Medicaid for failing to pay. People might be reluctant to sign up in the first place or worry about accruing debt for bills they can’t afford.

“Any premium is acting as a deterrent to enrollment,” she said. “If people think they have to pay a premium and they don’t have the money, they probably haven’t read the fine print.”

The waiver proposal for ARHOME that the state submitted earlier this year described a plan to increase premiums in 2022 to between $22 and $27 for those above the poverty line, depending on income. Failure to pay would still not have led to a loss in coverage, but would have incurred a debt to the insurance companies rather than the state.

CMS will allow the state to continue charging premiums to beneficiaries above the poverty line for one more year to allow “a planned phase-out of the policy,” giving Arkansas time to communicate the change to beneficiaries and make necessary operational changes. State officials said the current $13 per month premiums will continue through 2022. (From this point forward, any debt for unpaid premiums will be up to the insurance companies to collect, rather than the state. However, both the old waiver and the new waiver prohibit reporting the debt to credit bureaus, referring the debt to collection agencies, or taking legal action to collect the debt.) 

Medicaid waivers like ARHOME are intended to allow states to experiment with new initiatives to further the objectives of the Medicaid program. States are supposed to evaluate these demonstrations or pilot programs to test a hypothesis about the benefits of policies like premiums or work requirements. In her letter to the state, Brooks-LaSure wrote that the decision to deny authorization for premiums was informed by research in other states with similar waiver programs, which showed that the premiums “resulted in shorter enrollment spells, and were associated with lower initial enrollment rates and increased obstacles to accessing care in several states.”

In Arkansas, Brooks-LaSure wrote, the state’s evaluation of Arkansas Works likewise indicated that “beneficiaries had shorter, but more frequent gaps in coverage.”

Brooks-LaSure added that “premium requirements can exacerbate health disparities,” pointing to research from several states that showed the barriers to enrollment created by premiums were worse for Black beneficiaries and lower-income beneficiaries.

The ARHOME agreement with the feds will go into effect on January 1 and run through 2026. It will continue to use private insurance plans to cover most beneficiaries. In addition to the changes to co-pays, the state’s proposal outlines a number of other new features, including: incentives to encourage wellness and “economic independence” in the form of small rewards offered by the private plans; moving beneficiaries to traditional Medicaid if they are deemed “inactive,” meaning they don’t use their private health plan at all; a reduction in retroactive Medicaid coverage for new enrollees from 90 days to 30 days; efforts to hold the insurance companies accountable in terms of health outcomes, as well as mechanisms to curb cost growth for the insurance plans; and new programs for rural health, maternal and infant health, behavioral health and certain at-risk populations. Some of these new initiatives are still in development and will require additional federal approval.

Two days after the feds rejected premiums in Arkansas and Montana, the Biden administration rescinded the authority for work requirements (as well as premiums) for a Medicaid waiver in Georgia that had been approved by the Trump administration. Georgia was the last state that still had waiver authority for Medicaid work requirements, though the state had not yet implemented the policy. The Biden administration has now formally revoked approval in ten states, according to the Kaiser Family Foundation, with other states withdrawing after receiving approval. 

The Arkansas work requirements have been suspended since a federal judge halted the policy in March 2019. The program required certain beneficiaries to report their hours worked each month to the state Department of Human Services; if they were not working, they could instead report participation in job training programs, job searches or certain approved volunteer activities. If beneficiaries failed to comply, they would be kicked out of the program and lose coverage. Over the course of 5 months in 2018 and 2019, more than 18,000 Arkansans lost their health insurance due to the policy before it was halted by the federal courts.

State officials aren’t giving up on work requirements in the future, even if the policy is dormant for now: In the waiver proposal for ARHOME, Arkansas officials stated their intent to seek an amendment to the waiver “if federal law or regulations permit the use of a work and community engagement requirement as a condition of eligibility in the future.”

The only trace of the policy that remains in the current incarnation of ARHOME: Beneficiaries may earn small rewards from the private insurance companies for participating in health improvement or work-related activities. The insurance companies are required to offer four wellness-related incentives and one for “economic independence.” 

“The rewards may be redeemed in the form of a gift card, which beneficiaries will have several options to choose from,” said Max Greenwood, vice president of government and media affairs for Arkansas Blue Cross Blue Shield, one of the insurance companies that provides coverage to Medicaid expansion beneficiaries. “Beneficiaries can earn rewards ranging from $15 to $200, and also may be eligible for multiple rewards in any given benefit year.” 

This story is courtesy of the Arkansas Nonprofit News Network, an independent, nonpartisan news project dedicated to producing journalism that matters to Arkansans.


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SD- Medicaid expansion to appear on SD ballot

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[ MM Curator Summary]: Enough votes were obtained from people who wanted more benefits.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.


South Dakota voters to weigh in on expanding Medicaid


PIERRE, S.D. (AP) – A proposal to expand Medicaid eligibility in South Dakota will appear on the November ballot. The secretary of state’s office announced Monday that Constitutional Amendment D was validated after an estimated 38,244 people signed petitions to put in on the ballot. That was well above the level needed.

Medicaid is a federal-state health insurance program for low-income people. South Dakota is one of 12 states that has not accepted federal incentives to expand Medicaid eligibility, according to the Kaiser Family Foundation.

If voters approve, the program would be made available to 42,500 additional South Dakotans in its first year, according to the nonpartisan Legislative Research Council.

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CMS Says Children’s COVID-19 Vaccine Counseling Visits Covered by Medicaid



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[ MM Curator Summary]: CMS will now require COVID vaccination counseling as part of the EPSDT program.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.


On Dec. 2, the Centers for Medicare & Medicaid Services (CMS) announced that Medicaid programs must cover COVID-19 vaccine counseling visits provided to children as part of the Medicaid Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. This action is part of the Biden-Harris administration’s winter plan to respond to COVID-19 amid the emergence of a new variant of concern, omicron.

COVID-19 vaccine counseling visits will fall under COVID-19 vaccine administration, and as such will be federally matched at 100% under the American Rescue Plan Act. The law was enacted in March 2021 and provides a 100% federal match for COVID-19 vaccines and vaccine administration during the public health emergency and for one year after the end of the emergency. Read more about the American Rescue Plan Act’s health-related provisions in this previous blog post.

Medicaid programs will also be required to cover stand-alone vaccine counseling visits, federally matched at the regular match rate, for all pediatric vaccines under the EPSDT benefit.


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Medicaid now certifies kids for free lunch in SC, several other states



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[ MM Curator Summary]: More states are using Medicaid enrollment as a proxy for free school lunch, saving duplicate application efforts.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.



COLUMBIA, S.C. (AP) — The U.S. Department of Agriculture has added eight states to the 19 where students receiving Medicaid coverage will be automatically added to the program offering free or reduced-price school lunches.

A news release Tuesday says those states are Alabama, Illinois, Kansas, Louisiana, Maryland, Minnesota, North Carolina, and South Carolina.

The department says this expands demonstration projects that have certified more than 1 million students for free means and nearly 260,000 for reduced-price meals since the 2012-2013 school year.

It says the 27 states now involved represent about 75% of students nationwide.


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Advocates Build Back Betters CHIP Medicaid Changes Support NY Families

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[ MM Curator Summary]: The latest version of BBB/ “the Infrastructure Bill” still includes Medicaid components for 12 months continuous enrollment funding and making federal CHIP funding permanent.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.




ALBANY, N.Y. — The $1.75 trillion Build Back Better Act will soon get a vote in the U.S. Senate, and in New York, advocates say it could mean major improvements to health coverage for lower-income adults and children.

The Georgetown University Center for Children and Families said states would be required to provide 12 months of continuous eligibility for children in enrolled in Medicaid and the Children’s Health Insurance Program (CHIP).

Lara Kassel, coalition coordinator for Medicaid Matters New York, said Build Back Better also would increase postpartum coverage for new mothers, from 60 days to 12 months.

“We don’t want someone to suddenly, 60 days after they’ve given birth, be without coverage,” Kassel asserted. “We know that transitioning from program to program is not always successful. It’s not always affordable for someone. And so, to have the economic security of Medicaid coverage is really critical.”

New York is among 24 states already offering continuous one-year eligibility for children in Medicaid and CHIP, but just over half do not. Supporters of the bill say they want it passed by Christmas, but with increasing inflation, detractors are concerned about the cost, and could push for trimming its scope.

Build Back Better would also permanently extend federal funding for CHIP, which provides coverage to 6.8 million children whose family income is still low, but above the Medicaid eligibility level.

Joan Alker, executive director of the Center for Children and Families, said the bill would remove financial uncertainty for many families who depend on CHIP to insure their kids.

“Hopefully this will provide an opportunity, with stability in the CHIP program, to allow states to try to get to the finish line here and get all kids covered,” Alker contended.

The Children’s Health Insurance Program currently has federal funding through 2027.
Nearly 93% of eligible New York children are enrolled either in Medicaid or the state’s CHIP program, “Child Health Plus.”

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Tennessee Republicans can’t stop Biden’s Medicaid expansion plan

[ MM Curator Summary] The journos are starting to gloat about being able to force expansion onto non-expansion states.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.


Biden has a plan to expand Medicaid without actually expanding Medicaid. This is how it works.


A new White House proposal to offer nearly free health insurance to millions of low-income Americans would accomplish the same goal as previous efforts to expand Medicaid in Tennessee but would cut the need for state funding or approval from state lawmakers.

The plan – part of President Joe Biden’s sweeping “Build Back Better” agenda – would subsidize insurance purchased through the Affordable Care Act, commonly known as Obamacare, for impoverished Tennesseans who don’t qualify for TennCare, the state’s Medicaid program.

The proposal has the same aim and impact as Medicaid expansion but would not actually expand TennCare in any way. Instead, it would cover the same low-income population while sidestepping the primary obstacle preventing Medicaid expansion in Tennessee – state Republicans.

“It takes them completely out of the picture. It’s the federal government using federal funds to subsidize health insurance,” said John Graves, an expert on health care reform at Vanderbilt University Medical Center. “There is nothing the legislature can do about this.”

If the Biden proposal survives a divided Congress and is enacted into federal law, it could be transformative for Tennessee and other deep-red states where Medicaid expansion has long been a political non-starter.

But the transformation would be temporary. Biden’s proposal funds the new insurance subsidies for only four years. To extend the subsidies beyond 2025, Biden or his successor would need to secure more funding through a new law.

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What is the TennCare ‘coverage gap?’

TennCare, which is jointly funded by the federal and state government, provides health insurance to about one-fifth of Tennesseans, including many children, pregnant people, disabled adults and families who live at or below the poverty line.

But because Tennessee leaders repeatedly rejected Medicaid expansion, TennCare has a significant coverage gap: It does not cover childless adults — no matter how poor they may be — unless they fall into some other eligible category. 

This leaves no affordable insurance option for individuals who make less than $12,880 per year or couples who make less than $17,420, according to federal poverty guidelines. These people are poor enough to conceivably qualify TennCare but are not eligible since they don’t have children or a disability.

This is where the Biden plan kicks in.

The new federal subsidies would cover the entire Obamacare premiums for Tennesseans who live below the poverty line and aren’t eligible for TennCare or some other form of subsidized health insurance. It is estimated that about 120,000 Tennesseans fall into this gap, according to legislative analyses from the Kaiser Family Foundation and the Center for Budget and Policy Priorities.

For people impacted by this law, the subsidized Obamacare coverage would appear largely similar to the low-cost insurance they could have received through Medicaid expansion. Insurance would ultimately come from the same companies, like BlueCross BlueShield of Tennessee, and participants wouldn’t pay premiums but may face some small copays.

To a person on the receiving end of this coverage, the most significant difference would be how you sign up. Instead of joining TennCare under Medicaid expansion, enrollees will instead need to purchase a subsidized insurance plan through

Mandy Pellegrin, policy director at the Sycamore Institute, a nonpartisan think tank in Nashville, said this additional step may present an obstacle for some Tennesseans, causing a few eligible people to get lost in the process of choosing a coverage plan.

But beyond this small caveat, the proposal brings renewed optimism to efforts to insure the poor in Tennessee, Pellegrin said. Biden’s plan has “excited” advocates for Medicaid expansion who’ve grown exhausted of being stonewalled by lawmakers, she said.

“They are completely removed from this,” Pellegrin said. “It is 100% a workaround.”

Tennessee GOP stopped Medicaid expansion for years

Medicaid expansion, made possible under the Affordable Care Act in 2014, allowed states to grow their Medicaid programs to cover millions of low-income residents who were not previously eligible and unlikely to have insurance. Under the terms of the law, the federal government covered 90% of the cost of insuring these new enrollees.

Most states seized the opportunity to expand Medicaid while a minority rejected expansion, citing cost concerns or political objections to Obamacare in general. Additional states expanded years later due to political shifts or voter initiatives, and today there are just 12 non-expansion states – all of which are controlled by Republicans.

Tennessee is among the most steadfast of these holdouts.

Despite research showing expansion would benefit the poor and rural hospitals, and public polling that most Tennesseans support expansion, the state’s Republican supermajority have trounced every proposal to expand TennCare – even attempts from within their own party.

Former Gov. Bill Haslam presented an expansion-like plan in 2014 but it was promptly killed by lawmakers. Sen. Richard Briggs, R-Knoxville, a doctor, has repeatedly tried and failed to pass expansion bills. Democratic lawmakers fruitlessly push for expansion each year, but don’t wield enough power to advance a bill without Republican allies.

The debate was briefly revived after the election of Biden, who campaigned on a promise to improve Obamacare and woo non-expansion states to finally expand. Biden’s strategy was clear: offer a deal so sweet that no state could turn it down.

It didn’t work.

In a coronavirus relief law passed early this year, Biden offered to pay billions to hold-out states if they finally decided to expand. Tennessee could’ve gained as much as $900 million in two years on top of the federal government covering 90% of the expansion cost.

Tennessee’s Republican leadership said in March they would at least consider Biden’s new offer, but to date they have taken no action. In the eight months since Biden’s offer, lawmakers convened for legislative session three times and no serious discussion on expansion has occurred.

None of the other non-expansion states took Biden’s offer either.

Biden’s proposal must get through Congress and past Sen. Joe Manchin

While the Biden proposal completely sidesteps the state lawmakers in Nashville, it does require the approval of Congress in Washington D.C.

The expanded subsidies are part of a $1.85 trillion spending package that also includes universal preschool and large investments in efforts to combat climate change. Republicans balked at the price tag, and the legislation is likely to need votes from every Democrat to pass the Senate.

For now, fate of the proposal appears to hinge on a familiar thorn in Biden’s side – Sen. Joe Manchin.

Manchin, a centrist Democrat from West Virginia who wields significant political power because of his deciding vote, spoke in opposition to the proposal last month. He argued it was unfair for the federal government to pay for subsidies in the 12 non-expansion states when the rest of the country, including West Virginia, shouldered a portion of expansion costs for years.

“For states that held out to be rewarded 100% is not fair,” he said.

Other Democrats have tried to counter this argument. Georgia Sen. Raphael Warnock, who represents a holdout state, stress federal tax dollars collected in Georgia are funding Medicaid programs that low-income Georgians can’t join.

The status quo is not fair to them, Warnock argued. The same argument could be made for Tennesseans.

“People of Georgia are paying taxes for health care that they cannot access while subsidizing health care in West Virginia and in other states,” Warnock said.

The USA TODAY Network contributed to this story.

Brett Kelman is the health care reporter for The Tennessean. He can be reached at 615-259-8287 or at

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Closing Medicaid coverage gap could widen hospital margins, report says



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Subsidizing exchange plans in non-expansion states could add $12B to hospital profits.



The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.



If the Build Back Better Act goes into effect, hospital margins in the 12 states that have not expanded their Medicaid programs will increase by an estimated $11.9 billion, according to a Nov. 4 report by USC-Brookings Schaeffer Initiative for Health Policy.

Through the Affordable Care Act, states can extend their Medicaid programs to adults under age 65 with incomes below 138 percent of the federal poverty level, but 12 states have not done so.

In those 12 states, people with incomes below 138 percent of the federal poverty level are mostly ineligible for subsidized coverage. But the current draft of Democrats’ Build Back Better Act wants to fill the coverage gap.

Here are five things to know:

1. The current draft for the Build Back Better Act would fill the Medicaid coverage gap by making people below the poverty line in those 12 states eligible for ACA marketplace coverage. More than that, it would change marketplace coverage by eliminating all premiums and cost-sharing for people with incomes below 138 percent of the federal poverty line. This would add services that are covered by Medicaid but not the marketplace.

2. By making these changes, the report estimates that hospital margins in the 12 states would rise by $11.9 billion if the Build Back Better Act went into effect in 2023. The reason for this improvement is because hospitals would be paid for services they’re delivering anyway but aren’t currently being paid for. Additionally, more patients would be seeking care because of increased coverage, which would raise profits.

3. Hospitals in these states also would have smaller Medicare disproportionate share hospital payments. This is because the payments use a formula that looks at the national uninsured rate and the distribution of uncompensated care across hospitals. Both of these items would change.

4. If policymakers instead chose a federal Medicaid plan, these hospitals would receive smaller increases in margins at $3.6 billion. A federal Medicaid plan would most likely pay hospitals less than marketplace plans, according to the report, leading to hospitals receiving less revenue and less patient volume for uncompensated care.

5. The draft Build Back Better Act could help patients by allowing hospitals to provide care even if they have fewer resources. However, it could also allow hospitals to accept higher profits and increase costs, therefore not helping patients.


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