No Medicaid expansion, no coverage for some -
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No Medicaid expansion, no coverage for some

Thousands of Nebraskans will check out their health insurance options beginning Oct. 1, but many of those who were intended to benefit from Obamacare are expected to be left out.

They likely will earn too little to buy subsidized private insurance on the federal exchange, and they will continue to make too much to receive Medicaid.

Wendy Lewis of Omaha is among them.

The divorced mother of three, who has multiple sclerosis, works part time as a restaurant cashier. Her income of about $12,800 a year makes Lewis ineligible for Medicaid. But she would fit within an expanded Medicaid program envisioned as part of the Patient Protection and Affordable Care Act, or Obamacare, if she lived in a state that agreed to the expansion.

The 2010 law, intended to cover millions of uninsured Americans by 2014, assumed that every state would expand Medicaid with a heavy infusion of federal funds. But a court challenge led to states having options, and Nebraska is among at least 21 states that have rejected the expansion, saying it would be too costly.

The Affordable Care Act's authors expected Medicaid expansion to extend coverage to more than 15 million Americans, the Urban Institute reported, or about half the number of uninsured people intended to be covered. The law seeks to provide more coverage and more preventive care, resulting in fewer emergency room visits and less catastrophic illness, eventually lowering health care costs.

The gap in coverage to people like Lewis could put that goal in jeopardy and pinch hospitals such as the Creighton University Medical Center and the Nebraska Medical Center, which will lose some federal money on the assumption that they will treat fewer uninsured people. The gap will pressure clinics for low-income families, which have more requests for appointments than they can book. And it will affect patients such as Lewis.

Lewis, 38, was diagnosed with multiple sclerosis about 10 years ago. Three times she has temporarily lost vision in one eye. She gets exhausted when stressed or hot or when she overdoes it. She has numbness and tingling in her hands and feet. Her left leg drags behind her sometimes, and at times she's sluggish. The symptoms come and go.

For Iowa, modified expansion is choice

Iowa and Nebraska have taken different paths when it comes to Medicaid expansion.

Iowa has adopted a modified form of the program set up by the Affordable Care Act, while Medicaid expansion has stalled in Nebraska.

State Sen. Kathy Campbell of Lincoln, chairwoman of the Nebraska Legislature's Health and Human Services Committee, said she hasn't given up hope, however. Campbell, State Sen. Jeremy Nordquist of Omaha and their staffs continue to look at possibilities, including the modified plans of Iowa and Arkansas.

“We'll do some additional research into those plans ourselves,” said Campbell, who last session introduced a Medicaid expansion bill that was blocked by opponents.

Gov. Dave Heineman has said Nebraska can't afford Medicaid expansion.

He wrote this month that delays in some provisions of the law indicate “the overall approach of Obamacare is impracticable and unworkable.” He called for the law to be delayed or repealed altogether.

Iowa Republicans and Democrats reached an agreement this spring on Medi- caid expansion. Gov. Terry Branstad — like Heineman, a Republican — signed the compromise in June. The U.S. Department of Health and Human Services still must approve the plan.

Michael Bousselot, a policy adviser for Branstad, said the Iowa program isn't really Medicaid expansion, but that if the federal government wants to call it that, that's OK.

“In Iowa, we're all about results,” he said. Iowa leaders call it the Iowa Health and Wellness Plan.

It calls for those in the program with higher income levels —- 101 percent to 138 percent of the federal poverty level — to enroll in commercial health plans available through the health insurance marketplace, or exchange. Instead of receiving tax credits, those participants will have their insurance premiums paid by Medicaid.

In the second year, many participants in the Iowa plan will have to pay a monthly premium of up to $10. However, that premium, paid to the state, would be waived by participation in a wellness program that includes an annual physical, a health risks assessment, smoking cessation and other activities. Thus, Bousselot said, participants “invest in their own health” and have an incentive to stay healthy.

Rick Ruggles

Nevertheless, she has managed to stave off the worst effects of her disease with the assistance of the Nebraska Medical Center and some pharmaceutical companies.

“I hate having to ask for help,” Lewis said. “I had no choice.”

The majority of those who would benefit from expanding Medicaid are childless adults, although some parents, some disabled people and others would qualify, too.

Though a person in Lewis' situation might qualify for Medicaid now, with income of around $10,300, Medicaid expansion places the income ceiling at 138 percent of the federal poverty level. For one person this year, that would be $15,856. For a family of four, it would be $32,499.

The federal government is supposed to cover 100 percent of the Medicaid expansion the next three years, then 95 percent and eventually 90 percent from 2020 on. Even if the federal government fulfills that pledge, opponents say, the cost of Medicaid expansion will rise higher than expected.

One study, by University of Nebraska Medical Center researcher Jim Stimpson, and another study, by a consultant hired by the Nebraska Department of Health and Human Services, arrived at somewhat similar numbers regarding the number of people who would use an expanded Medicaid and how much it would cost.

Stimpson estimated 54,942 Nebraskans would join Medicaid expansion, if offered, in 2014. The consultant, Milliman Inc., estimated in its mid-range projection that 49,207 would join the program.

By 2020, Stimpson said, 79,998 would be in the program, costing the state $36.9 million and the federal government $332.2 million.

Milliman estimated 79,593 would be in the program by 2020 at a cost of $32.3 million to the state and $358.1 million to the federal government.

Because more people are expected to be insured under the Affordable Care Act, the federal government intends to gradually reduce special payments — called Medicare “disproportionate share” payments — to hospitals that serve many uninsured patients.

Scott Wooten, chief financial officer at Alegent Creighton Health, said his system provided $41 million in uncompensated care for uninsured and underinsured people in 2012-13.

Wooten said Alegent Creighton received $18.1 million from disproportionate share payments in 2012-13 and that such payments might decline by about one-fourth over the next four years. Alegent Creighton hospitals that receive those payments are the Creighton University, Bergan Mercy and Immanuel Medical Centers in Omaha and Mercy Hospital in Council Bluffs.

It's uncertain how much uncompensated care — or, at least, inadequately compensated care — would diminish because of Medicaid expansion. Wooten said Medicaid pays 83 percent of medical service costs. Plus, he said the demand for health care would go up if people had Medicaid through the expansion.

Nevertheless, Wooten said, Alegent Creighton, like the Nebraska Hospital Association and many other hospital entities, supports Medicaid expansion. Either way, treating those who struggle to get medical care is the right thing to do because “that's who we are and that's our mission,” Wooten said.

The Nebraska Medical Center delivered some $34 million in uncompensated care in 2011-12, the most recent year provided by that hospital. It received “disproportionate share” money totaling $11.4 million in 2012 and expects a total decline from that source of $10 million in the next six years, said Erin Mass, the hospital's manager of reimbursements.

Mass said there currently are no plans to reduce financial assistance to needy patients and no discussions about reducing any other services.

“As the environment changes, we'll just continue to re-evaluate the policy (on financial assistance) and see if that's still working or not,” Mass said. “There's a lot of things that could be looked at in order to save money.”

Lewis has received care virtually for free at the Nebraska Medical Center. She has undergone chemotherapy treatments for her multiple sclerosis, intravenous steroid therapies and other MS treatments.

Pharmaceutical companies give her some medications, and she declines to take expensive drugs that she would have to buy. When she received chemo for her MS, she chose not to take an expensive medication for nausea that she would have had to pay for, she said. It made more sense, she said, just to gut out the nausea.

She had feared her disease would progress to the point where she would be in a wheelchair by now, but she remains upright and well much of the time. She knows it's the generosity of institutions that keeps her going.

“So they're kind of my safety net right now,” said Lewis, who recently moved with her children into her boyfriend's place.

“I'm still walking and talking,” she said. “For the most part, I'm doing pretty good.”

A spokeswoman for the Nebraska Department of Health and Human Services said medical services do exist for the uninsured. They include community health centers, rural health centers and emergency rooms, she said.

“There are options that are available now, and those options would continue” without Medi- caid expansion, Kathie Osterman said.

Andrea Skolkin, chief executive officer of South Omaha-based OneWorld Community Health Centers, said her clinics provided about $6.5 million in uncompensated care last year through charity and bad debt, up from $4.9 million in 2011.

The Charles Drew Health Center in northeast Omaha provided $1.9 million in uncompensated care last year, CEO Richard Brown said.

Community health centers have received money from the Affordable Care Act to expand. OneWorld, for instance, received federal money that helped Skolkin add two new buildings on its South Omaha campus. Charles Drew has expanded to part-time clinics in four Omaha Housing Authority buildings.

Skolkin nevertheless said her agency has 600 appointment requests for adults each month that she can't accommodate. Those people are encouraged to use the agency's quick-care center on the South Omaha campus. Skolkin hopes to hire a pediatrician and a family practice doctor in the near future.

“It would make our budget work a lot better if we had a little more Medicaid coming through the clinic,” she said.

Some currently uninsured people will be able to use federal subsidies to buy commercial insurance at the online exchange, or marketplace, as of Oct. 1. People at 100 percent to 400 percent of the federal poverty level are expected to be eligible for some kind of assistance, or subsidy, said Andy Williams, a spokesman for Blue Cross Blue Shield of Nebraska.

An Urban Institute study last year indicated that of those in Nebraska who would have qualified for Medicaid expansion, close to 30 percent would qualify for some subsidy for private insurance. Those are the people who are between 100 percent and 138 percent of the federal poverty level.

Williams said it wasn't yet clear how high those people's premiums would be or how big a subsidy they would receive. Blue Cross, Coventry Health Care, CoOportunity Health and Health Alliance Midwest have said they will offer plans, but their premium rates won't be made public until after state and federal approval.

Opponents of Medicaid expansion say the federal government, with its shaky budget, can't be relied on to fund as much of the program as it says it will.

Jim Vokal, head of the Platte Institute for Economic Research, said estimates of the cost of expanding Medicaid also tend to understate the numbers of people who will leave private insurance plans for less-expensive Medicaid. That happened in Arizona and Maine, states that expanded their Medicaid programs before the Affordable Care Act, Vokal said.

Medicaid expansion is “a very costly program, and the numbers aren't going to add up in favor of the taxpayer,” he said. Vokal said it would be nice if everyone had insurance, “but we can't do it breaking the backs of taxpayers.”

Wendy Lewis doesn't care about the politics of Obamacare and Medicaid expansion. She just wants insurance.

The medical needs of her three children are covered by a state program called Kids Connection. She said caseworkers have suggested that she quit her job to qualify for Medi­caid. But she wants to work, and supplements her income at the restaurant by working at a pumpkin patch at Halloween. Further, she needs her income to support her children.

“I'm trying to make the best life for the kids that I can,” Lewis said. “Christmas has always been in February, when I get my tax return. I mean, it's a sad reality. Hey, it's whatever works. Some kids don't get Christmas at all.”

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