These measures demonstrate a broad understanding that the Biden administration is unlikely to be able to deliver on its promise to expand health care. And they come amid growing fears that the impending end to the Covid-19 public health emergency could lead to the expulsion of millions of people from Medicaid and fears that Obamacare grants that have helped millions of people buy coverage does not expire at the end of 2022.
In Oregon, Democrats passed a bill in March to establish a basic health plan, the details of which are being refined by a working group that began meeting this week. In Kentucky, Republicans approved $4.5 million public funds this spring to implement a basic health program, which was signed into law by the state’s Democratic governor. An estimated 85,000 Oregonians and at least 37,000 Kentucky residents will be eligible to enroll in the plans as early as next year.
“Because the federal government has failed in so many ways to provide access to health care for Americans, Oregon is stepping in,” said Jonathan Frochtzwajg, head of public policy and grants at the Cascade AIDS Project and one of the members of the Oregon task force. “Congress, and especially the Senate, is broken, and the states need to make up for it.”
A basic health program provides low-cost insurance to people who earn up to twice the federal poverty level — about $55,000 for a family of four — and don’t qualify for Medicaid. New York and Minnesota offer plans with little or no premiums, copayments or deductibles, a key selling point for sponsors.
“Co-pays and bonuses are a huge reason people don’t have access to care,” said Oregon Rep. Rachel Prusak, a nurse practitioner who led the basic health program at the Legislature as Chair of the House Health Care Committee. “From a clinician’s perspective, if we don’t, then what?”
Unlike other provisions of the Affordable Care Act, which have been the subject of intense partisan clashes, the basic health care program finds champions even among some Republicans, who see it as a way for low-income workers salary to earn more money or to work overtime. without fear of losing their insurance because they are no longer entitled to Medicaid.
“Kentucky isn’t known for great health indicators, and we’re doing our best to really address some of the gaps and barriers in the system,” said Kentucky Rep. Kim Moser, a Republican who chairs the House. Health and Family Services. Committee and is a registered nurse. “We know this is the group of people who go in and out of health coverage.”
When the Centers for Medicare & Medicaid Services issued a rule in the spring of 2014 creating the basic health program, Minnesota and New York jumped on it. Both had state-run programs that covered people who weren’t eligible for Medicaid, so the new policy amounted to a giant federal subsidy for plans they already had in place.
“We were a little surprised, if you go back to the early days of the Affordable Care Act, that only one other state had a basic health plan in place from the start,” said Chuck Johnson, deputy commissioner of the Minnesota Department of Human Services. “For us, it was sort of obvious.”
A handful of states, including Oregon, were interested in the program but did not move forward because health officials assumed people would sign up for subsidized market plans when they earned too much to qualify for Medicaid. . They didn’t expect so many people to find this coverage unaffordable.
For example, a 40-year-old man earning about $26,000 a year would have had to pay about $140 in monthly premiums for the second-cheapest Silver Plan before Congress increased market subsidies last year, according to the Kaiser Family Foundation.
“There was a dawning realization that coverage just wasn’t as affordable as it should have been,” said Jennifer Tolbert, the foundation’s director of public health reform. “It’s a good option, but there were a lot of people who just couldn’t afford the cover.”
Earlier this year, Oregon health officials found that more than a third of Oregonians uninsured before the pandemic said losing their Medicaid coverage was one of the main reasons they didn’t. had no health coverage, even though they should have been eligible for subsidies on the exchange.
“We’re talking about people whose income fluctuates between Medicaid and the market, but who don’t actually fluctuate between Medicaid and the market. They go between Medicaid and are uninsured,” said Jeremy Vandehey, director of the Oregon Health Authority’s Health Policy and Analysis Division.
At the start of the pandemic, Congress prohibited states from removing people from Medicaid rolls even if their income increased. Oregon’s uninsured rate fell from 6% in 2019 to an all-time high of 4.6% in 2021. Oregon’s black uninsured rate fell from 8% to 5%.
Proponents see the basic health plan — which evolved from state conversations about creating a public health insurance option — as a way to preserve those coverage gains and sustain improvements in health care. health equity as the end of the public health emergency looms.
“When we think of who benefited from not losing insurance, it’s people of color,” said Adrienne Daniels, acting director of integrated clinical services at the Multnomah County Health Department and a member of the group of work developing Oregon’s basic health program. “I don’t want Oregon back.”
Of the 300,000 people enrolled in Medicaid but expected to no longer be eligible when the public health emergency ends, Oregon health officials predict about 55,000 will be eligible for the basic health program. An additional 30,000 people enrolled in exchange plans are also expected to qualify.
In Kentucky, advocates have been calling for a basic health plan for years, but work accelerated last year when lawmakers passed a bill to explore the establishment of a bridging health insurance scheme. A task force, which met last summer, concluded in its final report that a basic health program “would enable people who would otherwise lose health care coverage through Medicaid to be able to to accept work and salary increases and eliminate the disincentive to accepting a pay or work increase.
A feasibility study conducted for the state by health consulting firm Milliman determined that 40% of people in the basic health program, estimated at about 37,000, would previously have been uninsured.
“It’s clear to see where the gaps are and which populations technically have coverage options, but not coverage options that work for them,” said Emily Beauregard, executive director of advocacy group Kentucky Voices for Health.
Critics, however, believe states could instead focus on more affordable exchange coverage instead of creating a new basic health program. Connecticut, for example, plans to join a handful of states that use state dollars to subsidize market plans for low-income residents.
Kaiser Permanente, in a letter to CMS earlier this month, called the basic health program “an inelegant and potentially market-undermining program.” Hospitals have also expressed concerns about reimbursement rates under the Basic Health Program and argued that this should be a temporary fix.
A CMS spokesperson declined to comment on conversations with states, but said in an email that the agency “encourages all states to explore the creation of a BHP if they believe it would be beneficial to provide more affordable comprehensive coverage to its enrollees”. The spokesperson added that the Biden administration believes the so-called state innovation waivers “represent an exciting opportunity for states, and the departments stand ready to help states obtain waivers.”
Oregon plans to submit its application for a basic health program at CMS later this year, with enrollment expected to begin around the middle of next year.
A spokesperson for the Kentucky Cabinet for Health and Family Services said the goal is to enroll people this fall for coverage starting in January.
And West Virginia could be next.
A Republican House delegate, who is a former Medicaid recipient, is working with health care advocates to build support around his bill to create a basic health program during interim legislative meetings this summer, and West Virginia’s Senate Majority Leader has sponsored the accompanying bill in the Senate.
“It seems so simple to me,” said delegate Evan Worrell. “It’s about taking care of people. I don’t think it’s about politics.