More About Jesse Cross-Call

Jesse Cross-Call

Jesse Cross-Call is a Policy Analyst in the Health Policy division of the Center on Budget and Policy Priorities. In this role he examines issues related to the implementation of health reform and provides information and technical assistance to state and local officials, providers, and nonprofit organizations who are working on issues related to expanding coverage to the uninsured through Medicaid and the new health reform marketplaces.

Full bio and recent public appearances | Research archive at CBPP.org


Hospitals Benefiting From Medicaid Expansion, Report Finds

September 5, 2014 at 10:52 am

Hospitals in states that have expanded Medicaid as part of health reform are seeing a large drop in uninsured patients and higher-than-expected revenues, a new report from the PricewaterhouseCoopers (PwC) Health Research Institute finds.  It’s the latest evidence of the Medicaid expansion’s benefits for states, their businesses, and their residents.

Examining financial data for the first half of the year from the country’s three largest health care providers, PwC found a 47 percent drop in admissions of uninsured patients at affiliated hospitals in Medicaid expansion states.  This suggests a sizable drop in uncompensated care — consistent with a nationwide survey of hospitals by the Colorado Hospital Association after the first quarter of the year.  PwC also found that the rise in the share of patients with health coverage boosted providers’ revenues even more than they had anticipated.

Meanwhile, the Urban Institute projects that hospitals in the 23 states that have not yet expanded Medicaid (see map) will lose out on $157 billion in reimbursements between 2013 and 2022.

This PwC report is one of several indicators of the growing gap between states that have expanded Medicaid and those that haven’t.  The Medicaid expansion is driving large gains in health coverage, while states that haven’t expanded risk forgoing those gains as well as millions of dollars in savings.

Wisconsin and Wyoming Tally Fiscal Cost of Rejecting Health Reform’s Medicaid Expansion

August 28, 2014 at 12:00 pm

Recent budget reports from Wisconsin and Wyoming show that their failure to adopt health reform’s Medicaid expansion is costing them millions of dollars in forgone budget savings.

In Wisconsin, the legislature’s nonpartisan Legislative Fiscal Bureau estimates that the expansion, which covers non-elderly adults with incomes up to 138 percent of the poverty line, would have saved the state $206 million in the 2014 and 2015 fiscal years combined.

Governor Scott Walker chose instead to extend Medicaid coverage to adults only up to 100 percent of the poverty line through a separate waiver.  This means that the federal government is paying for the expanded coverage at the state’s regular Medicaid matching rate of 59 percent, rather than the much higher matching rate for health reform’s Medicaid expansion.  (For states that expand to 138 percent of poverty, the federal government will pick up 100 percent of the cost through 2016 and no less than 90 percent thereafter.)  The difference in matching rates is the main reason for the $206 million in forgone savings.

Wisconsin could still save between $261 million and $315 million over the 2016 and 2017 fiscal years by adopting the expansion during next year’s legislative session, the report estimates.  Gov. Walker has justified his opposition to it by arguing that the federal government would ultimately renege on its financial commitment, but those fears are unfounded.

In Wyoming, the state health department projects that the Medicaid expansion would save the state $50 million a year on other health programs for low-income uninsured residents.  As a result, Governor Matt Mead is moving to advance the Medicaid expansion during the coming legislative session.  More than 17,000 uninsured residents would gain access to coverage under the expansion, the Urban Institute estimates.

The 27 states (including Washington, D.C.) that have adopted the Medicaid expansion are already seeing dramatic gains in health coverage and reductions in the cost of providing uncompensated care to the uninsured.  Wisconsin, Wyoming, and the other 22 states that have not done so could realize similar benefits.

States Seeking to Expand Medicaid Through Waivers Can Learn From Arkansas, Iowa, and Michigan

August 22, 2014 at 11:05 am

The federal government is considering proposals from Pennsylvania and Indiana to adopt health reform’s Medicaid expansion through a demonstration project, or waiver, and New Hampshire will soon submit its own.  The experience of the three states — Arkansas, Iowa, and Michigan — that have expanded through a waiver suggests that while the federal government will work with states to craft reasonable expansion plans, there are limits to the programmatic flexibility it will grant, as we explain in a new paper.

Waivers provide states with additional flexibility in how they operate their Medicaid programs, but they cannot be used to impose onerous requirements that make it difficult for eligible individuals to gain and maintain Medicaid coverage.  This principle has informed how the Department of Health and Human Services (HHS) has responded to waiver proposals so far.

Among the takeaways:

  • States may not disenroll people with incomes below the poverty line for non-payment of premiums.  While Iowa has received approval to charge beneficiaries with incomes between 50 and 100 percent of the poverty line modest premiums starting in 2015, the state will waive premiums for individuals who complete health risk and wellness assessments or attest to financial hardships.  Importantly, the state cannot disenroll individuals from coverage if they do not pay their premiums.
  • States may not require individuals to pay cost-sharing charges above what is allowed under Medicaid rules.  Medicaid cost-sharing rules provide states with significant flexibility while providing significant protections for beneficiaries that are intended to minimize barriers to necessary health care services.  The rules include special protections barring cost-sharing for children and pregnant women and for certain services such as family planning, emergency services, and maternity care.  People with incomes above the poverty line may be charged higher amounts, and providers cannot deny services to people with incomes below the poverty line who cannot afford to pay.  States must apply these protections to the newly eligible adults regardless of whether states expand Medicaid through a waiver.
  • States may not overly restrict certain benefits.  States have significant flexibility regarding benefits for newly eligible adults and can largely align their benefits with the benefits that private market plans provide.  Still, HHS has provided very limited waivers of Medicaid benefits.  And in Arkansas and Iowa, which are enrolling some or most of their expansion populations in private plans offered in the health insurance marketplaces, HHS has required that states augment marketplace benefits to ensure beneficiaries have access to the same benefits than if they were enrolled in regular Medicaid.
  • States can’t condition Medicaid eligibility on employment or participation in work search activities.  In December 2013, Pennsylvania Governor Tom Corbett proposed a Medicaid expansion waiver that would require anyone working fewer than 20 hours a week to register with the state’s unemployment compensation program and engage in 12 work search activities per month to remain eligible for Medicaid coverage.  Those judged not to be in compliance would have their health coverage revoked.  Gov. Corbett subsequently submitted a revised proposal to HHS that would charge beneficiaries differential premiums based on whether they are working or engaged in work search activities.  In response to Pennsylvania’s proposal, HHS has indicated that it is unlikely to approve waivers that condition either Medicaid eligibility or premium amounts on compliance with work search or other work-related activities.

Click here to read the full paper.

Federal Medicaid Matching Rates Have Remained Stable, New Study Shows

August 14, 2014 at 1:03 pm

Some state policymakers opposed to health reform’s Medicaid expansion continue to argue that the federal government will likely renege on its commitment to permanently pick up nearly all of the cost.  Some assert that Congress frequently changes the formula that determines what share of states’ Medicaid costs the federal government will cover (also known as the FMAP).  As we noted in February, that’s false, and a new report from the Urban Institute concurs.

The report finds that policymakers have only cut the FMAP once, in 1981, when President Reagan and Congress enacted a temporary cut.  The most recent FMAP changes were temporary increases to give states fiscal relief during the past two economic downturns.

States are headed down divergent paths based on whether they have expanded Medicaid.  The 27 states (including the District of Columbia, see map) that have taken up the Medicaid expansion are experiencing large gains in health coverage.  As a result, hospitals are providing much less uncompensated care than just a year ago.

Unfounded concerns of a future drop in the federal matching are no reason for the remaining states to stay on the sidelines and miss out on the many benefits of expansion.

Medicaid Expansion Decisions Leading States Down Divergent Paths

July 16, 2014 at 2:24 pm

As a growing number of reports increasingly make clear, a state’s decision whether to expand Medicaid as part of health reform has real-life effects on its residents and its businesses.  In the 26 states and the District of Columbia that have expanded Medicaid (see map), the positive benefits are already playing out.  Here’s some of the latest information:

  • Hospitals are providing less uncompensated care.  In Arizona, hospitals reported that the Medicaid expansion is the chief reason for a 30 percent decline in the amount of uncompensated care they have provided so far this year, compared with a year ago.  The Colorado Hospital Association found a similar decline in charity care through April when it surveyed hospitals in 15 states that have expanded Medicaid and 15 that have not.
  • Medicaid expansion is driving large gains in health coverage.  A survey conducted by the Urban Institute finds that while the uninsurance rate is dropping across the country, states that have expanded Medicaid have seen a drop in the percentage of non-elderly adults who are uninsured by more than one-third — a 37.7 decline — while the uninsured rate fell by only 9 percent among states that haven’t expanded.  A survey from the Commonwealth Fund found a similar trend.

States can opt in to the Medicaid expansion at any time, allowing them to extend coverage to millions with the federal government picking up all of the cost of the expansion through 2016 (and nearly all of the cost in the years after), as we have written.  New Hampshire recently started accepting applications for its expansion, with coverage first available on August 15.

But states that refuse to expand leave a coverage gap, where people below the federal poverty line have income too high for Medicaid under prior eligibility rules but too low to qualify for federal subsidies to purchase coverage through the marketplaces.  This means we’re likely to see more stories as in Tennessee where, due to the coverage gap, a couple separated so the wife’s income would be low enough to maintain her Medicaid coverage.