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


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.

Virginia Should Be Wary of New Medicaid Poll

April 25, 2014 at 1:56 pm

There’s a big reason to question the accuracy of a new poll of Virginians from Christopher Newport University, which the Washington Post and other news outlets have highlighted, that purports to find significantly less enthusiasm for expanding Medicaid as part of health reform.  Here’s what policymakers and media should keep in mind.

The pollsters say they found that Virginians’ support for expansion dropped from 56 percent on February 3 to 41 percent now.  What the pollsters do not fully acknowledge, however, is that they asked the question in two markedly different ways, making this a highly misleading, apples-to-oranges finding that doesn’t necessarily show a shift in public opinion:

  • On February 3 the question was asked:  Medicaid is a health care program for families and individuals with low income that is funded by both federal and state tax dollars. Currently, Virginia is faced with a decision about whether to expand the Medicaid program to cover an additional 400,000 mostly working poor Virginians who are uninsured. In general, do you support Medicaid expansion or oppose it?
  • But on April 24 poll the question was asked:  In [the Medicaid expansion] debate, the Democrats propose to subsidize private insurance for 400,000 uninsured and low income Virginians by using federal Medicaid money that would otherwise not come to Virginia. Republicans oppose this expansion because they fear the federal Medicaid money will not come as promised, and also say the current Medicaid program has too much waste and abuse and needs reformed before it is expanded.

Thus, unlike in February, Virginians in the most recent poll were asked whether the state should expand Medicaid only after they were read the straw man argument that the federal government will renege on its commitment to fund nearly all the costs of the expansion.  As we have explained, the history of Medicaid’s financing shows that federal funding has remained remarkably steady for decades.

Virginia policymakers should not be swayed by a misleading poll when deciding whether to expand Medicaid.  They should instead keep in mind that the state’s own analysis found that expanding will save the state more than $1 billion through 2022.  For the state, and the 400,000 uninsured Virginians who stand to gain health coverage from the expansion, the expansion remains an incredibly good deal.

Two Takeaways From New Hampshire and Michigan’s Medicaid Expansions

March 31, 2014 at 11:40 am

New Hampshire’s legislature has passed and Governor Maggie Hassan has signed into law legislation that will expand Medicaid as part of health reform effective July 1.  This means that combined with Michigan, where expansion takes effect tomorrow, an additional 600,000 uninsured people will be newly eligible for Medicaid coverage.  It also means a majority of states have taken health reform’s Medicaid expansion, as our map shows.

For policymakers in Maine, Missouri, Utah, Virginia, and other states currently debating whether to expand, the news from New Hampshire and Michigan offers important lessons:

  • Federal officials are willing to work with states to craft reasonable expansion plans.  The legislation passed in New Hampshire directs state officials to pursue a demonstration project — often called a “waiver” — that would use Medicaid dollars to buy coverage for newly eligible beneficiaries through the marketplace.  If approved, this approach would be similar to those in place in Arkansas and Iowa.

    New Hampshire likely will gain federal approval for its demonstration project because it steered clear of onerous provisions being discussed in other states that would make it difficult, if not impossible, for people to gain and maintain coverage.  For example, policymakers in Pennsylvania and Missouri have discussed tying people’s Medicaid eligibility and premium obligations to whether they are working or actively looking for work.  Such provisions have no relation to the purpose of Medicaid, which is to provide health coverage to people with low incomes.

  • States can expand at any time, but the sooner, the better for states and the uninsured.  The Medicaid expansion is a great deal for states, but especially so from now through the end of 2016 while the federal government pays the entire cost of covering the newly eligible.  (The federal government will pay no less than 90 percent of the cost in the years thereafter.)  While New Hampshire’s proposed waiver will not take effect until January 1, 2016, newly eligible beneficiaries will be able to enroll in the state’s existing program on July 1 of this year.  This is a win for both the Granite State’s finances and for the uninsured.