Why I voted YES on the (much) less than perfect Medicaid Expansion compromise

NOTE:  I actually wrote this way back on May 24th, the day after we passed the so-called “Medicaid Expansion” compromise bill.  But I never finished it, because I was waiting until we got more information on exactly how the whole mess plan would work – but we are still waiting on that, and waiting on approval from the Feds, so I decided to go with what I have. Which isn’t much.  Although here are links to two summaries of the plan – and while one is by the Iowa Medical Society and the other is by DHS, neither of which are particularly objective reporters, I found them somewhat informative:

Health and Wellness Plan Summary.pdf

DHS Health and Wellness Plan overview.pdf

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Yesterday (May 23rd) the Iowa Legislature passed Senate File 446, which started out as the Health and Human Services Budget bill but which was amended to include legislation creating a state-wide “Health and Wellness Plan” – let’s call it the HeWeP for short – that is intended to provide health insurance coverage to approximately 158 thousand low-income Iowans who cannot currently afford private health insurance coverage but who for some reason do not qualify for Medicaid coverage.  The HeWeP was the result of  last minute, closed door negotiations between members of House and Senate leadership and the Governor – the Senate was provided with info on the compromise early Wednesday afternoon and most of House didn’t get the details until about 9:30 p.m. Many of us were  shocked and dismayed to discover that the basic structure of the “compromise” plan is much more akin to the Healthy Iowa plan (aka TerryCare) originally proposed by the Governor than to strict Medicaid Expansion, which is what the Senate (and the majority of health care and social justice type organizations) had originally supported.

I have many concerns with the HeWeP, and I have absolutely no doubt that simply expanding Medicaid would have resulted in more Iowans being covered at a lower cost to the State – but I voted Yes on SF 446 anyhow – in short because, at the end of the day, it does some very good things (see below) and because it was better than letting the Governor negotiate Iowa’s response to the ACA mandate directly with the Federal government, which is what could have happened had the Legislature gone home without passing anything.

So … Tell me all about the Iowa Health and Wellness plan!

Sorry, no can do, because even though I insisted on reading the all of the portion of the HHS bill that sets out the structure of the HeWeP before voting on it (seriously, there was a big push for the House to debate/vote on the bill Wednesday night, even though we were provided with the sixty page summary of the bill – not the bill itself, just a summary – less than two hours prior to our midnight voting deadline! I.e., before any of us had actually read the summary! Much less the bill!), it’s short on details and parts of it just don’t make sense. But I’ll tell you what I (kind of, sort of) know:

Is the Health and Wellness Plan actually Medicaid Expansion?

Yes and no. The HeWeP is being billed as “Medicaid Expansion” because even though the folks covered under the HeWeP aren’t going to be covered by “regular” Medicaid, Iowa is accepting Medicaid dollars to fund the plan. So unlike the Governor’s original proposal (TerryCare), which would have required a lot of State money and which would have triggered an increase in  property taxes state-wide, the HeWeP takes full advantage of the federal funds available under the ACA – during the first three years the plan is in operation, the Feds will pick up 100% of the cost of expanded coverage (after that it’s a 90/10 federal/state split, which is still better than regular Medicaid). So that’s a good thing – but one of the primary “pluses” of covering this group of people by simply expanding Medicaid eligibility was the fact that we know how Medicaid works and the state wide mechanism to deliver Medicaid benefits is already in place. In contrast, the HeWeP’s delivery mechanism is complicated, confusing, and parts of it don’t even exist yet.

So – the HeWeP expands the number of Iowans who are eligible to access federal Medicaid dollars to cover health insurance coverage, but the coverage they are able to access, and the conditions they will have to comply with in order to maintain that insurance, will be different.

Who Will be Covered under the Health and Wellness Plan?

1.   The HeWeP will provide health insurance coverage “comprable to what State employees get” (whatever that means), free of charge, to the approximately 68,000 uninsured Iowans whose household income is less than 100% of poverty (about $11,000 for a one person household) and who are currently ineligible for Medicaid (because they aren’t caring for a child, pregnant, over 65, or blind or disabled). This is a really big deal, both for Iowa and for Clinton County.

2.  The HeWeP will also provide access to health insurance coverage to an Iowan – say, Bob- who has household income between 101-138% of poverty (up to about $15,500 for one person). Bob will hypothetically be able to choose between various health insurance plans offered through Iowa’s Insurance Exchange (hypothetically because so far no the insurance exchanges aren’t yet operating) and for the first year of coverage, Bob’s premiums will be paid by the government using federal Medicaid funds.  And IF Bob participates in certain “wellness activities,” Bob’s insurance premium will continue to be paid in full during the second year of coverage. Probably.

What are these “wellness activities”? Nobody knows … but presumably they’ll include things like annual check ups, maybe a requirement that smokers quit smoking, maybe a requirement that obese people lose weight or participate in a fitness program.  If Bob does NOT participate in the recommended wellness activities, then in order to maintain insurance coverage Bob will have to pay a monthly  premium, which can equal no more than 2% of Bob’s annual household income (So if Bob earns $15,000 annually, his annual premium couldn’t exceed $300 – or $25 a month). Presumably if Bob doesn’t pay the premium, he will lose his coverage – how soon, and for how long, is unclear.

So unlike true Medicaid Expansion, which would have utilized the delivery mechanism already in place to provide all Iowans under 138% of poverty with the same coverage provided to current Medicaid participants, and which would have provided that coverage free of charge, the HeWeP creates a new and complicated program that could potentially provide coverage to the same number of Iowans, but the majority of those Iowans (it’s estimated that 80,000 to 120,000 of eligible Iowans will fall into the 101-138% group) will be required to either accomplish unknown wellness goals or pay a small monthly premium in order to maintain coverage.

The Governor refers to this requirement as “having skin in the game,” and insists that it will result in an overall healthier Iowa – the theory being that all of the folks in the 101-138% group will faithfully participate in the wellness activities (which will presumably make them healthier) because they’ll want to avoid being required to pay a monthly premium. Makes sense, right?

Well…. maybe it makes sense on paper, but I have concerns as to whether it will translate to real life.  We all know that we should work out regularly, and eat better, and stop smoking, and lose weight – but the majority of the general population doesn’t consistently do any of those things, right? Despite the fact that we know that by not doing these things, we are risking all sorts of unpleasant health and quality of life consequences. I tell myself all the time that if I just started working out on a regular basis, I would feel better and be healthier – but I don’t work out, ever. Even though I have a relatively flexible work schedule, and I belong to a gym, and own all sorts of shoes and clothing specifically designed to facilitate working out, and I know that I would feel physically and emotionally better if I worked out, and thus my quality of life would improve. I intend to do it, I really do – in fact, almost every day I tell myself that tomorrow is going to be the day I start working out – but … I don’t.

And the people who will be required to jump through the as yet undefined hoops so as to be able to continue to be eligible for health insurance coverage are the working poor – i.e., they are employed and earning more than 100% of poverty but less than 138% of poverty. The majority of folks that I represent in court fall into the “working poor” category, and let me tell you – these people live hard lives, and they often have not very enjoyable jobs at which they have to work really hard to make not very much money, and they are often dealing with extremely stressful home lives (because limited financial resources tend to make everything more stressful) – and they tend to be pretty darn exhausted most of the time. And sometimes when one is really exhausted one doesn’t pay as much attention as one should to things like routine medical check ups and monitoring one’s blood pressure. So I really wish that I could tell this group of people “Hey, guess what, you are going to be covered by Medicaid starting January 1st!”  instead of “Hey, guess what, starting on January 1st you may be able to purchase health insurance coverage online, and the government will pay for it for a year or two so long as you follow all the rules, but if you don’t follow all the rules the government won’t pay for it – and by the way, we’re not sure what the rules will be, but we’re working on them.”

So, in summary:  I voted for the Health and Wellness Plan because when and if we are able to fix the problems with it and get it up and running, it will provide health insurance coverage for a lot of Iowans who would otherwise find it difficult if not impossible to obtain coverage. It is far from perfect, and it could have been so much better, but it is the best we could do –  and in the coming session, I promise to work with my colleagues to  do what I can to help make it better.

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About Representative Mary Wolfe

Part time attorney; full time State Representative for Iowa House District 98 (East Clinton County)
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2 Responses to Why I voted YES on the (much) less than perfect Medicaid Expansion compromise

  1. Hi Mary, Since so much of health care costs and outcomes depend on life style decisions people make, strong incentives should be provided for individuals who make good life style decisions.

  2. Jerry says:

    Thanks, for posting. I understand the Iowa House was in a different situation that the US House, but the argument that we can fix it up better after it gets off the ground was used there, too. So far, the only fixes have made it weaker.

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