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Despite Red State Resistance, Health Law Supporters Foresee Medicaid Successes

By John Reichard and Rebecca Adams

January 24, 2014 -- Health law supporters are predicting long-term success in efforts to expand Medicaid to enroll millions more uninsured Americans, even in those states such as Texas whose governors are dead set against the overhaul.

"People really have to be willing to roll up their sleeves," says Ginny Goldman, an activist who has set her sights on Texas, perhaps the toughest nut to crack in the national fight over expanding Medicaid.

A recent decision by Utah's Republican governor, Gary R. Herbert, to pursue some form of Medicaid expansion this year gives hope to supporters of the law. The Democratic governor of conservative-leaning Kentucky said last week that 175,000 of his residents have signed up for Medicaid through an expanded version of the program or for health insurance through its health insurance exchange since Oct. 1.

A combination of factors could ease the path toward expansion in states whose leaders are opposed to the law. They include coalition building involving low-income residents, business interests, and hospitals and other health care providers. Branding the Medicaid expansion with a state's own imprint could allow Republican governors to claim economic benefits while maintaining their political opposition to the health law.

Goldman, director of a community organizing campaign for low-income Texans called the Texas Organizing Project, said at a recent Washington, D.C., conference that Texas is the state that has the most to gain from expanding Medicaid. Estimates are that 1.4 million to 1.7 million of its 6.4 million uninsured residents would get coverage if the state expanded Medicaid. Goldman spoke at the annual conference of Families USA, an advocacy group that backed enactment of the health law.

Other states, such as Washington, Kentucky, and California are reporting big enrollment numbers since they expanded eligibility for their programs on Jan. 1. Sorting out how many of those people actually are newly eligible is challenging—and it's clear that in a number of states many residents are not.

But in states like Texas, the number of newly eligible isn't in dispute. It's zero.

Pushing Back in Texas

In Texas "there's two challenges and their names are Ted Cruz and Rick Perry," quipped Goldman, referring to the state's junior senator and its governor.

"Immediately when Rick Perry first announced in 2012 that he was going to reject the Medicaid expansion money, we really sprung into action bringing uninsured families to the capital, having press conferences" and "really showing that people weren't just going to sit back and allow this decision to go forward without a fight," Goldman said.

Joining in the effort were Planned Parenthood, SEIU, other labor unions, "and more traditional partners" such as health providers, Goldman said. And there are "unusual partners" because the size of the uninsured population in Texas, she said.

"The Chamber of Commerce and Texas Organizing Project don't traditionally agree on many issues, but on this issue we're sitting at the table talking about the economic impacts that not accepting the Medicaid funds is having on the state, the number of jobs that are being lost," she said.

Goldman said there was bipartisan support in the legislature for a "Texas solution" that would make Medicaid expansion palatable in the state. Republicans and Democrats were ready to push forward some bills but Perry "slammed the door on that opportunity," she said. So Republican lawmakers "who were willing to go there with us had no reason to walk that plank," Goldman said.

"We measure success differently in our state," she said. Perry made the calculation that most people affected by the expansion probably wouldn't know about it or if they did find out about weren't going to vote or take any action, she said. "We counted it as a success that we communicated with over 400,000 Texans in 2013" about Medicaid expansion to counter that perception. She said 44,000 of them either pledged to take an action on behalf of expansion in 2014 or pledged to vote this year in upcoming elections.

Working uninsured Texans and home care workers were organized to "directly confront" Perry said. "They interrupted his state of the state speech," interrupted his press conferences, and forced him to meet with uninsured residents in his office in front of the press.

At the same time, Goldman wasn't forecasting a payoff any time soon. In states such as Texas, "I would say dig in, because it is going to be a long haul," Goldman said. "And then I would say look for the opportunities along the way" for smaller gains and local efforts that maintain momentum.

She said in Houston, for example, a "pay or play" effort is underway to require employers who don't provide coverage to pay into some kind of fund.

Utah: Doing Nothing 'Not an Option'

In Utah, "doing nothing is not an option," Herbert said last week.

The governor has not decided exactly what kind of approach to take, his spokesman, Nate McDonald, recently said. When the 45-day state legislative session begins this week, Herbert expects to begin work in earnest on figuring out the details.

"These questions you are asking are still being determined," McDonald told HealthBeat.

If the state decides to use a Section 1115 waiver to expand eligibility, it will have to be posted publicly so that the public can comment on it before the Centers for Medicare and Medicaid Services decides whether to approve it. A number of states are interested in using Medicaid dollars to buy coverage in the new marketplaces. CMS has already approved waivers in Arkansas and Iowa that pursue this approach. Government officials are currently reviewing a Pennsylvania request that follows this model.

Kentucky: Red State, Democratic Governor

Kentucky Democratic Gov. Steve Beshears said that 175,000 Kentucky residents have signed up for Medicaid through an expanded version of the program since Oct. 1 or through its exchange. Most are entering Medicaid, though he didn't break out the numbers and it wasn't certain that all those in Medicaid are newly eligible.

Beshears told the Families USA event that Kentucky is the only southern state to broaden the program and run its own exchange. Kentucky has been widely cited as a success story because of its lack of technical problems with its insurance website, its assertive outreach and its relatively high percentage of enrollments.

"Some might consider the commonwealth an odd choice to be leading the nation," Beshears said. He cited the stereotype of the state as behind the times and opposed to any growth in government.

"Classic red state persona, right? Wrong," he told the advocates.

Beshears was able to avoid some of the drama in other states because he took executive action to expand Medicaid and create a state-run marketplace. Bypassing the state legislature, he changed regulations to expand Medicaid and signed an executive order to put the state in charge of the exchange. Beshears has prevailed in court against challenges to the steps he took.

Kentucky's population has very poor health, he said, calling the state's statistics on disease and mortality "horrendous."

"I needed a big solution and along came the ACA and gave that big solution to me," he said, referring to the health care law (PL 111-148, PL 111-152).

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