No deadline looms for Medicaid expansion.
"There's no timeframe for when states have to act," said MaryBeth Musumeci, an associate director at the Kaiser Commission on Medicaid and the Uninsured. "Just because a state has not moved forward at this time, does not mean it may not make a different decision down the road."
Many states seem to be taking a wait-and-see approach about what action to take when it comes to providing health care coverage for low-income adults.
But the moves made by those seeking an alternative to Medicaid expansion -- while still receiving an influx of federal dollars -- could ultimately influence decisions made by Oklahoma leaders.
The country so far has been very much divided into "red" and "blue" states over this part of the Affordable Care Act, which health reform architects envisioned as providing Medicaid benefits to many of the working poor.
But when reviewing a legal challenge to the entire health reform law, the U.S. Supreme Court last year found that states essentially have the right to opt out of this expansion.
Out of the Republican-leaning states not to embrace Medicaid expansion, only Arkansas has submitted an alternative that's been approved by federal regulators.
This plan calls for the use of Medicaid dollars to pay for coverage provided by private companies who have plans on the new state marketplace exchange.
Arkansas is doing Medicaid expansion, but "just doing it in a different way than states doing it through the state plan authority," Musumeci said.
Perhaps, but there are still "some benefits package differences," between Medicaid and what the Arkansas private marketplace plans offer, she said. The state is including "wrap-around" benefits to pay for such gaps in coverage, according to Musumeci.
For example, federal Medicaid law gives "free choice" to beneficiaries when it comes to choosing family planning providers, Musumeci said. While marketplace plans have a limited network for providers, she explained that the Arkansas plan would cover the expense should someone choose an out-of-network family planning provider.
Federal authorities have accepted the Arkansas plan, which is set to provide benefits beginning Jan. 1. However, the plan submitted by Arkansas is considered a "1115 waiver" application, so it doesn't continue indefinitely; the Arkansas model is effective only through 2016.
"There will be an evaluation and assessment process that's done as a part of an 1115 waiver," Musumeci noted. It's unclear what will happen once the Arkansas plan hits its expiration date.
David Blatt, an advocate of Medicaid expansion and director of the Oklahoma Policy Institute, said the actions of other states will eventually influence each other, though the inaction of most states thus far has been purposeful.
"I think there is a national strategy to refuse to cooperate with the Affordable Care Act and do whatever possible to see the law fail," Blatt said.
Slowly, that inaction has begun to thaw, he noted.
"You have several governors in Arizona, Ohio, Pennsylvania ... where Republicans have concluded that expanding Medicaid is too good of an offer to turn down," Blatt said.
He explained how the Arkansas plan is similar to an Oklahoma-based program, Insure Oklahoma, developed by state leaders.
"As with the Arkansas approach, Insure Oklahoma uses public dollars to subsidize the purchase of private commercial health insurance. So, we already have the framework operating," Blatt said.
While the Insure Oklahoma program was imperiled when federal authorities balked at continuing to pay for a program targeting a similar population as full Medicaid expansion, negotiations between state and federal leaders resulted in a one-year extension for Insure Oklahoma.
Though some have been left out who previously could receive Insure Oklahoma assistance, Blatt seemed optimistic that the program could still be expanded.
"We can now expand Insure Oklahoma with some modifications to cover that larger low-income uninsured population that becomes eligible under the Affordable Care Act," Blatt said.
Despite the seeming inactivity in Oklahoma, Blatt said the state is not in a "static situation."
"Until now the line from the governor's office and from the speaker is that we will not expand coverage. But I think that as we move ahead over the coming months, the pressure will grow as other states fall into line or go join the line," Blatt said.
It's a queue that only includes Iowa at the moment as far as another state formally submitting an alternative to federal Medicaid expansion.
The Iowa proposal calls for enrollees to pay a $20 monthly premium, though that fee could be waived "by meeting specified health improvement activities," according to the Henry J. Kaiser Family Foundation, which has compiled information about the Iowa plan.
Musumeci noted that perhaps a bigger difference involves how the Iowa plan focuses on a more narrow population getting insurance through marketplace providers. Under the Iowa plan, those earning between 101 and 138 percent of the federal poverty level would receive premium assistance but receive coverage through insurers operating through the newly established statewide insurance marketplaces.
But Musumeci said that negotiations take place between federal health care authorities and states whenever such a "waiver" plan is submitted, so the final details of Iowa's proposal could change.
While Musumeci said there's no deadline for states taking action, "the federal funding, the 100 percent, is only available to states for the first three years" to cover the costs of Medicaid expansion. After that time period, the funding percentage decreases on the federal end, with states expected to contribute more -- a point often raised by those opposed to Medicaid expansion, though the long-term federal contribution after a phase-in period is supposed to remain at 90 percent.
Blatt said estimates show that roughly 150,000 Oklahomans fall into a "coverage crater" because of the gap created by the state not adopting Medicaid expansion and eligibility guidelines for the new marketplace insurance subsidies.
He said he expects Oklahoma legislators to seriously consider how to expand coverage to low-income Oklahomans in next year's legislative session.
"Mary Fallin was not going to be the first Republican governor to say yes to expanding coverage, but she may also not want to be the last," Blatt said.
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