After successfully resisting Medicaid expansion for four years, Republicans in the Virginia House have done an about-face and now support it. While the issue is pending, the Obamacare Truth Squad is sending one hard question a day about Medicaid expansion to Del. Chris Jones who, observers say, is the prime mover behind the switch. His responses, or lack thereof, appear below:
4/5/18 – Provider Tax: Wading into Quicksand with Cement Overshoes – Joe Biden said it best: the provider tax is a scam. At root, it is a way for states to pull more money out of Washington. Thus, relying on provider taxes has real consequences:
1) The national debt is $21 trillion and growing. At some point, the party has to come to an end. This means that Medicaid expansion is not on a sound actuarial footing. Why do you insist on building on quicksand?
2) Provider taxes make states more dependent on the federal government than they already are. Virginia is already far too dependent on federal dollars. Northern Virginia is dependent on the federal government for employment. The Tidewater area is dependent on the U.S. military. Why do you want to make Virginia’s budget even more dependent on the federal government and add to the risk we will face financial calamity when Washington is forced to stop spending like a drunken sailor?
3) What happens if Washington doesn’t approve of Virginia’s provider tax? Would you leave Virginia taxpayers on the hook for all the goodies stuffed into the House budget in expectation of free money from Washington, or would you amend the budget to take those items out? The same question pertains if Washington does away with provider taxes altogether (President Obama twice proposed this); changes the allowable provider tax rate; repeals Medicaid expansion (as has been discussed in both houses of Congress and the White House); or converts Medicaid to a block grant – how do you answer?
More questions about the provider tax:
4) According to the regulations, provider taxes must be broad-based. In stark contrast, the provider tax currently under consideration in Virginia only applies to private acute care hospitals, not all hospitals or all healthcare providers. Why do you expect Washington to approve Virginia’s proposed provider tax when it only applies to private acute care hospitals, not all hospitals? Has Washington ever approved such a narrowly-drawn provider tax before?
5) There can be no direct correlation between the provider tax and the Medicaid payment amount, according to the regulations. However, Virginia plans to use the tax to pay the state’s share of Medicaid expansion. How does this not run afoul of the ‘no correlation’ rule?
6) What happens to the budget if enrollment explodes way past projections in Virginia as it has everywhere else? Wouldn’t the provider tax be overwhelmed, thus forcing the state to cover the ballooning costs some other way?
7) Have you gamed out what would happen in Virginia if our experience tracks what happened in Connecticut? There, the provider tax situation changed over time – the tax burden on hospitals was increased and the amount paid back to them was decreased because of other state budget pressures. The hospitals very quickly became big losers. You can’t guarantee the same thing won’t happen here. How would you propose to solve the hospitals’ provider tax-induced problems under the Connecticut scenario?
8) Why do you want to raise the cost of healthcare with provider taxes? What are the systemic consequences of doing so, and how are you planning for them?
4/4/18 – How does Medicaid expansion increase the supply of healthcare providers in SW Virginia when the reimbursement rate is less than the cost of service? How does Medicaid expansion keep rural hospitals open if hospitals lose money on every Medicaid patient that walks in the door? If helping rural hospitals is the goal, wouldn’t it make more sense to help them directly (as the Thomas Jefferson Institute has proposed)? What alternatives to Medicaid expansion have you actually considered to increase the supply of medical services in SW Virginia? What bills have you patroned? NO RESPONSE
4/3/18 – The Medicaid expansion proposal in the House budget would set up a premium assistance program for individuals between 100-138% of FPL whereby they would “obtain health insurance coverage through a private health insurance plan.” This is essentially the ‘Arkansas plan’ put forth in Virginia by former Senator Watkins some years ago, which was soundly rejected. Because this plan became such a financial disaster in Arkansas, that state has been trying to scale it back to 100% of FPL, thus far without success (CMS has deferred action on Arkansas’ request). In addition, the House budget language proposes ‘skin-in-the-game’ premiums from program recipients based on a sliding scale. However, the experience of other states shows that most of the people don’t pay their premiums (see here and here). How can you justify trying to bring the Arkansas plan to Virginia when it is a known financial disaster, Arkansas has already confessed error and is desperately trying to get out of it, and skin-in-the-game premiums are just so much pie-in-the-sky? And what happens to your budget projections when you factor in that most people won’t pay their premiums? NO RESPONSE
4/2/18 – Maine’s Republican Governor is demanding that the state legislature “show me the money” before implementing Medicaid expansion there. State officials say it is “reckless” to assume that expansion would save the state money given the enrollment explosions and cost overruns in other states. They refuse to book the phantom savings you tout here in Virginia (e.g., putting inmates on Medicaid). Aren’t you being reckless by counting your chickens before they’re hatched? Why isn’t Maine’s cautious approach correct? NO RESPONSE
3/30/18 Quicksand – Medicaid expansion supporters sound pretty sure of themselves but, fact is, they were wrong about everything:
Diverting people to primary care instead of the ER does NOT reduce healthcare costs; in fact it INCREASES them. #TheyWereWrongAboutEverything
‘Medicaid expansion caused the number of ER visits to go up.’ Huh? Expansion was supposed to bring the number down. #TheyWereWrongAboutEverything
Greedy hospitals lost their bet that Medicaid expansion would bring them riches; reimbursements lower than expected, bad debt rising again.
Obamacare’s high deductibles and Medicaid Expansion-induced reimbursement cuts have put hospitals in financial distress. #TheyWereWrongAboutEverything
Hospitals losing money on Medicaid expansion patients, resort to cost-shifting. #ToldYouSo
Previous NY Medicaid expansion caused MORE racial disparity in access to cancer surgery
Cost shifting by Medicaid expansion patients to ACA exchange customers becoming unsustainable
Medicaid expansion crowds out private insurance by 15-50%
Managed care was supposed to be magic bullet for Iowa Medicaid, but losses climb to $450 million
“La. AG says Medicaid expansion has ‘exacerbated’ the state’s opioid crisis” – prescriptions doubled.
Question: if you succeed in expanding Medicaid, who do you expect to clean up your mess?
3/29/18 – Drag on the Economy: It’s been known for some time that, despite all the cheerleading, Medicaid expansion is a DRAG on the economy, not a boost. Here are 4 stories from 2017 (I’m happy to supply more upon request):
Medicaid expansion DESTROYS hospital jobs; it does not create them
Medicaid expansion discourages work; promises of ‘job creation’ never materialize
Labor-force participation is dropping in Medicaid expansion states http://www.richmondregister.com/opinion/obamacare-public-policy-malpractice/article_04064f86-006e-11e7-b1d7-6b3b1649976e.html
The only way to actually pay for Medicaid expansion is to raise taxes.
How can you push Medicaid expansion when it will so clearly HARM Virginia’s economy?
3/28/18 – Administrative Nightmares – I’ve heard that DMAS will not be able to handle the influx of Medicaid expansion enrollees and will push it to the counties. Where is the funding in the budget to reimburse the counties for this and how was the number derived? Second, Virginia has done next to nothing to verify Medicaid recipient eligibility thus far (remember the James O’Keefe sting video at the Richmond Medicaid office?). California has as many as 450,000 people enrolled in Medicaid expansion who are clearly ineligible or who might not be eligible, costing the state a billion dollars. Where is the funding in the budget bill for eligibility verification and how was the number derived? Third, how many state and federal dollars will be spent to administer the work requirement? Will it be less or more than the $374 million Kentucky will need to implement its work requirement over two years? Liberal critics say implementing a work requirement will be an administrative nightmare. How do you know they’re wrong? NO RESPONSE
3/27/18 – Bill Bolling in his recent editorial urged Medicaid expansion along the lines of the way it was done in Kentucky. The Kentucky plan contains a work requirement, as does the Virginia House GOP plan. GOP Medicaid expansion supporters claim this ‘conservative reform’ will reduce enrollment to manageable levels. However, Kentucky officials say even with work requirements, premiums, lock-out periods, anti-fraud provisions, and everything else they got in their Medicaid work requirements waiver, expansion enrollment will still be at least 437,521 in 2020, compared to the 188,000 maximum they initially expected. In light of Kentucky’s actual experience, not Bill Bolling’s romanticized view of it, what empirical basis do you have for believing that the Virginia House GOP work requirement will keep enrollment in check? Isn’t a work requirement just ‘conservative’ lipstick on a statist pig? With so many exceptions in the Virginia House GOP work requirement, what basis do you have for believing it will do much of anything at all? NO RESPONSE
3/26/18 – Inferior Health Outcomes: What about the studies that consistently show that patients on Medicaid have the worst health outcomes of any group in America—far worse than those with private insurance and, in some cases, worse than those with no insurance at all? NO RESPONSE
3/23/18 – From Virginians for Quality Healthcare (VQH): What is Virginia’s capacity to absorb 300,000 new enrollees? Where would these Virginians get medical care? Will they compete with the traditional Medicaid population for health care? Are there enough physicians in Virginia who accept Medicaid patients? Where are these individuals located, and would they have access to facilities where they live? Are new facilities needed? What kind of wait times will these new enrollees encounter to receive care? NO RESPONSE
3/22/18 – Contrary to popular belief, Medicaid expansion makes emergency room use go UP, not down. And, no, it doesn’t decline after a supposed initial rush. Here are just 3 of the most recent reports documenting this:
More evidence Medicaid expansion makes ER use go UP, not down.
Obamacare genius masterminds wrong again: “California ER use jumps despite Medicaid expansion”
‘Medicaid expansion caused the number of ER visits to go up.’ Huh? Expansion was supposed to bring the number down. #TheyWereWrongAboutEverything
Why do you support Medicaid expansion when it INCREASES, not decreases, ER use?
What legislation have you introduced to counter the ill effects of Medicaid expansion on ER use? NO RESPONSE
3/21/18 – “Earlier this month, President Trump released his budget for 2019, which cuts funding for Medicaid expansion, as do the House Republican and the Senate Graham-Cassidy proposals. The message is clear from both Congress and the White House — funding for Medicaid expansion program is unlikely to continue….” (article here). In light of these facts, how can you justify your ‘damn the torpedoes, full speed ahead’ push to expand Medicaid in Virginia? NO RESPONSE
3/20/18 – The bad news about Medicaid expansion keeps rolling in every day. Because expansion spiraled out of control in New Hampshire, Republican lawmakers there recently introduced legislation to reduce the eligibility threshold from 138 percent to 100 percent of FPL for childless able-bodied adults. The enrollment of 54,000 healthy childless adults under Medicaid expansion forced New Hampshire to cut reimbursement rates to doctors and to deny adequate treatment to children and adults with developmental disabilities, brain disorders, and other chronic issues. If the same thing happens after you expand Medicaid in Virginia, will you patron a bill to reduce the eligibility threshold? How much will you reduce doctor reimbursement rates? And how will you avoid giving the short end of the stick to the truly needy? How is it responsible to proceed in the face of known dangers and the horrible experience other states are having with expansion if you don’t have answers to these questions? NO RESPONSE
3/19/18 – In the American Spectator today: “A new study reveals that 21,904 Americans have died while withering away on Medicaid waiting lists in states that expanded the program under Obamacare. The victims were poor and disabled applicants herded to the back of the line to make room for able-bodied adults with incomes above the federal poverty level (FPL). Why would any state pursue such a cruel and unjust policy?” NO RESPONSE
3/9/18 – With so many doctors leaving practice because of Obamacare, and others rejecting Medicaid patients, what makes you think these additional 400,000 patients will even be able to see a doctor? NO RESPONSE
3/8/18 – How can you justify using the budget process for such major legislation? Mike Thompson wrote in an article published yesterday in the Jefferson Policy Journal, “Expansion of Medicaid should be debated, experts brought into serious committee hearings, public debates hosted by various organizations, votes taken by the House and the Senate on their individual bills, and differences hammered out in a conference committee. The House agreed to this four short years ago.” NO RESPONSE
3/7/18 – How can you push Medicaid expansion when you don’t know whether the federal government will let Virginia terminate the program if it doesn’t work out? There were opinions from think tanks early on that getting out of Medicaid expansion would not be legally possible. Those fears were reinforced just this week when, nine months after the request was first made, CMS refused to allow Arkansas to return its expanded Medicaid eligibility back to 100% of FPL. With Arkansas’ request put on hold, there is not a single instance of a state successfully getting out of Medicaid expansion. What happens if federal funding dries up and Washington won’t let Virginia out of the program? What happens to Virginia’s budget then, Del. Jones? Can you think of a bigger disaster? NO RESPONSE
3/6/18 – Stress Tests – Every single Medicaid expansion state has exceeded their enrollment projections by an average 110%, more than DOUBLE. Where are the stress tests, i.e., the studies that show what happens to state expenditures in Virginia if enrollment doubles past expectations here? If no such studies exist, how can you in good conscience push expansion without knowing what will happen to the state budget if your numbers are way off? What programs will you cut and what taxes will you raise if Medicaid expansion explodes here in Virginia like it has everywhere else? NO RESPONSE
3/5/18 – Exploding Enrollment – Every single Medicaid expansion state has exceeded their enrollment projections by an average 110%, more than DOUBLE. How do you know the same thing won’t happen in Virginia? NO RESPONSE
3/2/18 – Why is it a good idea to change Medicaid from a poverty program into a middle class entitlement? NO RESPONSE