By Robert Mann
“Any damn fool can make something complex; it takes a genius to make something simple.” – Pete Seeger
Des Moines – It was a simple proposition: Help the working poor become eligible for health insurance as quickly as possible. When Congress enacted the Affordable Care Act (ACA) in 2010, one of the law’s key provisions required states to expand Medicaid to those whose jobs pay them too little to qualify for the ACA’s premium subsidies but make too much to become eligible for their states’ existing Medicaid programs.
When it upheld the law in 2012, the U.S. Supreme Court struck down the Medicaid expansion mandate, making it voluntary. Twenty-four states (including D.C.) recognized the wisdom of the law’s simplicity and quickly folded millions into their existing Medicaid programs. Another 20 states, like Louisiana, refused.
The seven remaining states expanded Medicaid in sometimes complicated ways. One was Iowa. Officials here obtained a waiver allowing them to craft a hybrid Medicaid program. The results were disastrous.
A Medicaid waiver is what Sen. David Vitter promised in the recent governor’s race – an expansion tailored for Louisiana. Vitter said he wanted expansion “on Louisiana terms, certainly not Barack Obama terms.” And, he added, “I want to reform Medicaid, not expand the present system.”
Gov.-elect John Bel Edwards, however, promised a simple, sensible plan – folding people into the state’s existing managed care program. Doing so would immediately extend health care to hundreds of thousands of the working poor. “Bringing $16 billion of our taxes home is probably the most fiscally conservative idea that has been suggested to finance health care since Bobby Jindal took office,” Edwards said last October.
Edwards’ plan for Medicaid expansion is the wiser course. As Iowa’s sorry experience suggests, simplicity is the better way to cover quickly the greatest number of individuals. Not only will immediate expansion eliminate a lengthy wait for a waiver approval; it obeys the wise admonition, “If it ain’t broke, don’t fix it.”
If only Iowa’s Republican governor, Terry Branstad, had heeded that advice. Instead, he created a new program when his existing Medicaid system worked relatively well. In late 2013, Washington approved Iowa’s new “Marketplace Choice” program. Officials here forced many of the state’s working poor (those who earned between 101 and 138 percent of the federal poverty rate) into choosing insurance from one of only two private providers. Poorer workers enrolled in the state’s existing managed care plans.
The problem, however, is that Iowa officials designed an unworkable and overly complex expansion that promptly proved a failure. One of the insurance companies quickly became insolvent as premiums rose and the state misjudged the number of new enrollees into the health plans. Both companies eventually withdrew.
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