Perspectives in Policy - Spring 2013

Issue 3, 3/29/2013

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Perspectives in Policy - Spring 2013

In 2009, Congress passed and President Obama signed into the law the Patient Protection and Affordable Care Act, also referred to as the “ACA” or “Obamacare.” This legislation was big in size and scope and had many different provisions to the law dealing with healthcare. One of the provisions passed in the ACA was struck down by the United States Supreme Court.

The part of the law that was found unconstitutional by the Supreme Court deals with the expansion of Medicaid to nearly all low-income individuals under the age of 65. Since the court found this part of the law unconstitutional, it gives individual states the option to utilize the expanded Medicaid proposed in the ACA. Iowa legislators and Governor Branstad will decide this legislative session whether or not to expand Medicaid.

Expanding Medicaid costs money. Many of the perspectives presented here address how to best cover low-income Iowans who often don’t have access to quality health care. People disagree about what the cost to the federal government and states will be if Medicaid is expanded. Many studies have been done to address how these costs will be distributed and to whom leading to a variety of opinions on the expansion.

This issue of Perspectives in Policy will discuss those varying perspectives around whether Iowa legislators should choose to utilize the federal Medicaid expansion or not. Many different organizations, individuals and elected officials have their own ideas about the best way to cover low-income Iowans and this issue will discuss some of those ideas.

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Standing Firm - The Governor's Perspective

Governor Branstad has stood firm in his opposition to expanding Medicaid in Iowa and since then, he has noted his concern with Iowa taxpayers being stuck with large costs down the road because of his belief that the current federal budget deficit would demand cuts at some point. When referring to the cuts, Branstad said “What we’re saying is, let’s realize reality: the federal government is broke.” He strongly believes the federal government will renege on its promise leaving Iowa to pick up the enormous bill.

At a press conference where the Governor rolled his alternative plan out called the “Healthy Iowa Plan” he said, “This is a modern health plan that will pay providers to care for their whole population based on the quality of care they deliver,” Branstad said. “The Healthy Iowa Plan will also use personal responsibility measures that ask members to contribute at least a little to their health care.”

Branstad’s proposal would replace the current IowaCares program which provides limited coverage to roughly 67,000 low income Iowans.

The “Healthy Iowa Plan” would require participants to pay a portion for the services on a sliding scale. It provides incentives for wellness and prevention to encourage people to stay healthy.
While his plan has been praised by some, it has been criticized by Democrats and many health organizations.

Recently, Governor Branstad released some information about his plan to provide services to lower income Iowans. The Healthy Iowa Plan consists of:

  • Covering 89,000 Iowans
  • Total State Funds of $162 million:
    • – $42 million Polk County Broadlawns property tax levy
    • – $43 million in county MH/DS property tax levies (1/3 of existing levy capacity)
    • – $12 million existing state appropriation to the University of Iowa Hospitals & Clinics
    • – $24 million state appropriation ($8 million existing IowaCare appropriation; rest is new)
    • – $34 million in Medicaid “savings” that will be reinvested in the program
    • – $7 million in participant premiums that will be reinvested in the program
  • FY 2014 FMAP rate of 58.35%; total federal funds $227 million
  • $389 million in total funds for the program
  • $4,370 annual average benefit per individual enrolled

Governor Branstad is concerned about the potential cost to Iowa taxpayers if the federal government doesn’t live up to their promise. He believes his plan is realistic and sustainable for Iowans.

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Legislative Perspective - Senate President Pam Jochum (D-Dubuque)

Iowa Senate President Pam JochumMy parents brought their children up to be involved in our community, and to act when we had a chance to make a difference.

I was taught the same values by my teachers, many of whom were Catholic nuns. The good sisters taught with their words and actions that when you fail to speak up and do what’s right, you also fail to do your duty as a citizen. That’s why I believe Iowa cannot have two health care systems: one for those who can afford it and one for those who can’t.

Here are some of the consequences of dividing Iowans into the health care “haves and have-nots.”

Iowa families risk the loss of their home and bankruptcy if a parent or spouse or child becomes ill.

Local hospitals and health care providers are burdened with roughly one billion dollars each year in uncompensated care. The cost of that uncompensated care drives up insurance costs for every Iowa business and every family with health insurance. We can fix these problems, and we can do it this year.

Expanding Medicaid will make affordable health insurance available to all Iowans; make Iowa’s health care system financially secure; provide more access to mental health and disability services; and slow rising health care costs for Iowa families and Iowa businesses.

By expanding Medicaid, we will bring health insurance to 80,000 currently uninsured Iowans and preserve and improve health care for 70,000 Iowans currently on IowaCare.

I hope I’ve shown you that Medicaid expansion makes sense and saves money. But the most convincing argument I can offer is that expanding Medicaid is the morally right thing to do.

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Legislative Perspective - House Majority Leader Linda Upmeyer (R-Clear Lake)

Iowa House Majority Leader Linda UpmeyerThe Affordable Care Act gives states the option of expanding their Medicaid programs to enroll individuals earning up to 138 percent of the federal poverty level. In Iowa, this would add another 150,000 individuals to the program.

With so much uncertainty regarding funding at the federal level, I have concern that it may not be wise to enter into an agreement that relies upon steady federal funding. If the woes of the federal government continue, I worry that we will end up promising benefits that we will not be able to provide.

Additionally, expanding Medicaid would overload an already fragile healthcare program. The addition of 150,000 Iowans to Medicaid would spread resources out and possibly result in fewer services delivered to the entire population.

In states that have previously expanded their Medicaid programs, patients who were most in need of health services paid the greatest price.

In 2001, Maine expanded Medicaid based on promises that doing so would reduce the number of uninsured residents and would improve patients’ health and quality of life. Instead, Maine’s uninsured rate is the same today as it was in 2001 (12%). Additionally, while nearly 11,000 able-bodied, childless adults have Medicaid in Maine, more than 3,100 disabled and elderly are currently on a wait list to receive health coverage and services.
There simply are not enough resources to provide care to Maine’s Medicaid expansion population without sacrificing services to the neediest patients.

Arizona has had a similar experience with Medicaid expansion. Policy makers had to stop covering life-saving organ transplants for patients in order to cut costs. Instead of reducing the number of uninsured residents, Arizona now has a higher rate of uninsured (19%) than it did before it expanded Medicaid (18%).

Medicaid expansion poses a great risk to Iowa’s most vulnerable patients. The experiences in Maine and Arizona show what can happen to health and quality of life when states decide to expand. We should not risk Iowa patients being subjected to those same dangerous results. Instead, I believe we need to be focused on an Iowa solution that serves the needs of Iowans. I believe that needs to be developed here in Iowa, not in Washington, D.C.

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Supporting Medicaid Expansion - Tori Squires, Iowa Primary Care Association

Tori Squires Iowa Primary Care AssociationFor those of us who work in health care, the predominant legislative issue this year has been the state’s pending decision on accepting Medicaid expansion as allowed by the Affordable Care Act.

Instead of accepting Medicaid expansion dollars, Governor Branstad has proposed The Healthy Iowa Plan, which he has stated will expand the current limited-benefit IowaCare program. Very few details have been made available about what benefits will be included in the Governor’s program or where patients could access primary care, specialty care, and hospital services.

Six of Iowa’s 14 Federally Qualified Health Center (FQHCs) are medical homes for nearly 19,000 IowaCare patients, which gives us a frontline perspective of the severe limitations of the program. Our experience shows that IowaCare is a greatly flawed program that should in no way serve as the foundation for ensuring low-income Iowans have access to a full continuum of health care services and supports.

What few details we do know about The Healthy Iowa Plan reveals that, compared to federally-supported Medicaid expansion, it will provide services to thousands fewer Iowans (89,000 under the Governor’s plan compared to 150,000 through expansion), will cost Iowa taxpayers more money, and will not include access to mental health services, required through expansion.

Currently, the state’s 69,000 IowaCare patients must access primary care services at one of 13 medical homes. Patients are assigned to a medical home based on their county of residence and have no choice in where they get services. In many instances, a patient’s medical home is several counties and many miles from their home. If patients need hospital care, they must either go to Broadlawns in Des Moines or the University of Iowa Hospitals and Clinics in Iowa City – again this is assigned based on their county of residence.

Covered benefits through IowaCare are similarly limited. The program does not cover medications, mental health or behavioral health services, durable medical equipment (such as oxygen), home health services, or hospice. Medicaid expansion would cover all of these.

We believe the choice is easy. Accepting federal funds benefits more Iowans, provides better coverage, and allows Iowans to access services closer to home. Not accepting federal dollars and choosing instead to build on a deeply flawed program is a grave disservice to low-income Iowans and to all Iowa taxpayers, who will see their federal tax dollars being used to pay for Medicaid expansion in other states.

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CPC Perspective - Lisa Rockhill, Lyon County CPC

Lisa Rockhill Lyon County Iowa CPCAs counties are moving forward with the MH/DD redesign efforts, Medicaid expansion affords us the opportunity to look at services, especially to those individuals with persistent mental illness in a different manner.

Currently, we have been primarily focused on providing those in our communities with assistance for mental health treatment services, but many in our communities have not been able to access the medical services to treat chronic medical issues that many times go hand in hand with those diagnosed with persistent mental illnesses, largely due to the fact that access to those programs providing medical services to those without Medicaid or other insurances require trips to places sometimes hours away from our own communities.

The increase of Medicaid eligibility could mean better all around care for many who may have gone without coordinated care before. Sarah Kaufman, Henry County CPC states that, “By expanding Medicaid, people can now have access to treatment for both mental health and preventative care to help manage chronic medical conditions.”

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Update on Medicaid Expansion

Senate Democrats have offered what they consider a compromise to address the Governor’s concern over the current federal deficit and the lack of confidence he finds in the federal government’s long term commitment to pay for healthcare services if Iowa were to expand Medicaid. The compromise offered by the Senate Democrats would allow Iowa to pull out of the expansion if the federal government does not live up to their promise to pay for the services. This “opt-out” provision has been considered by Governors in other states who share Governor Branstad’s concerns. While the compromise did not receive an immediate favorable or unfavorable response from the Governor and other opposing Republicans, there does seem to be some understanding that a compromise will be inevitable.

The discussion about Medicaid expansion is expected to continue through much of the remainder of the 2013 legislative session. Please visit to keep up-to-date on the issue.

Perspectives in Policy is a publication of the Iowa Developmental Disabilities Council. If the issue of Medicaid expansion is one that affects you personally or something that you feel strongly about, we encourage you to use this information to talk with your elected officials. Your active participation is an essential part of a legislative process that will ultimately determine the future of healthcare for many low income Iowans. 

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