Has Medicaid expansion helped or hurt the program? Indian-American Medicaid chief Seema Verma, Gov. John Kasich offer differing views

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Seema Verma, administrator of the Centers for Medicare and Medicaid Services, announced the proposal Thursday. (Washington Post photo by Jabin Botsford)

WASHINGTON – One of President Donald Trump’s most vocal Republican critics released a report Tuesday (Aug. 21) extolling the benefits of expanding Medicaid. Meanwhile, on Capitol Hill, the federal official in charge of Medicaid testified in Congress about why the expanded program is unsustainable.

Four years ago, Ohio Gov. John Kasich bucked his Republican Party to accept the Affordable Care Act’s offer to add more low-income residents to the government-run health care program. On Tuesday, the state highlighted success it has had through Medicaid expansion.

Medicaid is currently at a crossroads. The Trump administration is pressing forward with efforts to allow states to add work requirements to be eligible for the coverage at the same time as three red states, Nebraska, Utah and Idaho, are giving voters the chance to decide on whether to implement expansion through November ballot initiatives. What happens in this debate could determine the future of the safety net program for the poorest Americans.

During a Senate hearing on Medicaid fraud also Tuesday, CMS Administrator Seema Verma in her prepared remarks said, “Medicaid expenditures have grown rapidly and are consuming ever-increasing shares of State budgets.”

She blamed expansion for exploding the federal budgets because the federal government has paid 100 percent of costs to cover the expansion population and by 2020 will pay 90 percent into perpetuity. So far, 33 states and the District of Columbia expanded Medicaid to cover people earning up to 138 percent of the poverty line or about $16,000 a year.

“The structure of how we’ve set this up, it really does create an incentive for the states to spend more and more,” she said. She said Medicaid should be shifted from an “open-ended entitlement to a fixed amount of money,” which is a common talking point of Republicans who believe Medicaid funding to states should be capped.

Kasich, for his part, has been a proponent of block grants or per capita caps for Medicaid, but during a press conference Tuesday to tout his state’s expansion program, he sounded a dire warning about the program’s future.

“It is affordable now, (but) if the federal government plays games and tries to put us in a perilous fiscal position, we will have to change this position on Medicaid expansion. There is no way that we can put our state deep in the hole and wreck economic development and more prosperity,” Kasich said. The Ohio report showed that an additional 700,000 individuals a year were covered by the expansion, and 89 percent of them were previously uninsured.

For Kasich, who is one of 17 GOP governors to expand the program, perhaps the strongest argument he has to skeptical members of his own party is that 290,000 people who received the benefits have since left the rolls because they were started working or began earning more. Most of the recipients told the state that having insurance helped them find or keep their job.

Notably, Ohio is among the states that filed a waiver this year to add work requirements to its Medicaid program, pushed to do so by a GOP-led legislature still irked that Kasich expanded the program. The decision to answer the Trump administration’s call to apply for such waivers infuriated state Democrats who have called on Kasich to rescind the application. Ohio officials says most of the able-bodied adults on Medicaid are already working and that it would affect around 36,000 enrollees.

Critics of adding eligibility parameters to Medicaid say it sets up low-income people to fail because typically reporting work or asking for an exemption requires doing so online, if they know to do it at all.

In Arkansas, the first state to implement work requirements, 83 percent of beneficiaries who were supposed to go online to report activity didn’t, according to Joan Alker, a law professor at Georgetown University, who tracks these programs. “With two strikes against them, it’s clear that many beneficiaries appear to be unaware that they were even sent up to bat,” she wrote in a blog post.

Verma has defended the work requirements, saying it provides an incentive to lift people out of poverty. “This is the idea of helping people to obtain independency and the skills they need,” she told senators.

At the hearing, Sen. Tom Carper, D-Dela., talked about the moral imperative of the Medicaid program and used one politician to make his point. “One of my best friends is this guy named Kasich. We were freshman in Congress together 400 years ago,” Carper said. ” He was asked why he decided to expand Medicaid. And he said, ‘When I stand at the pearly gates someday and I’m trying to get into heaven and they ask me what did you do to deserve getting into heaven, I want to be able to say that when people needed health care, I helped them get it.”

Also, at the hearing, Verma assured Democrats that if a pending lawsuit against the Affordable Care Act was successful, she would help Congress write legislation to ensure people with pre-existing conditions stay protected.

“I am deeply concerned about individuals with pre-existing conditions. My job is to implement the law, but if the law changes in some way, I would work with Congress to make sure we had protections in place for people with pre-existing conditions,” she said.

Sen. Claire McCaskill, D-Mo., pressed Verma on this point, telling her that it’s “outrageous” there’s no plan in place to address this if the ACA is overturned by the courts, and said “there doesn’t seem to be any sense of urgency” in Congress to act. Sen. Heidi Heitkamp, D-N.D., later said it was “disingenuous” for the administration to say they believe in pre-existing conditions if they won’t defend them in court. Both senators are in difficult re-election fights and this is a top issue they’re campaigning on.

“Let’s not pretend there is any commitment here from the Department of Justice to preserve pre-existing conditions for the American people,” she told Verma. “It’s not your decision, but I want that on the record.”

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