Billions of dollars, better health care for Pennsylvania's poor and election-year politics are riding on Republican Gov. Tom Corbett's bid to bring Medicaid expansion money to the state under the 2010 federal health care law.
It could mean health insurance for hundreds of thousands of the working poor. It could mean a pipeline of new money for hospitals, doctors and other health care professionals who routinely care for people without insurance. And it could have political implications for Corbett as he runs for re-election against a Democratic challenger who is critical of his plans.
The federal government's public comment period ended Friday, and negotiations are expected to begin this month on Corbett's 124-page plan submitted in February. The outcome is anything but certain.
Pennsylvania's application is asking the U.S. Centers for Medicare and Medicaid Services to break new ground on Medicaid policy, people who analyze and consult on states' Medicaid plans say, and it is not clear yet whether federal officials are ready to allow that.
Instead, the agency could stick to allowing the kind of changes, called waivers, it has allowed previously in other states. That could be bad for Corbett, a conservative who is heavily critical of President Barack Obama's landmark law and of Medicaid, the state-federal program for the poor and disabled. Corbett has sought to get the new money but make his plan distinct from the law, which he opposed and his fellow conservatives despise.
If some or all of his proposed changes are rejected, Corbett will face a decision on whether to take the federal government's offer in an election year when labor unions, hospital groups, the AARP, medical professionals and advocates for the poor want the Medicaid money to come to Pennsylvania.
"It's reasonable to expect that Pennsylvania will receive the same flexibility that other states have received," said Deborah Bachrach, New York's former Medicaid director and a partner with the law and consulting firm Manatt, Phelps & Phillips. "Whether or not CMS will go further depends on how the request is framed and the protections that would have to go along with the waiver."
The Corbett plan seeks several major changes to the Medicaid expansion as it was envisioned by Obama's law that sought to extend health insurance coverage to 30 million more people.
To start, Corbett wants to use the federal money earmarked for an expansion of Medicaid to instead subsidize private insurance policies for the working poor who would be covered under the Medicaid expansion. He also wants the private insurance policies to be free of some of Medicaid's coverage rules, such as its permissive rules for when coverage kicks in.
CMS has not waived retroactive eligibility in other states, Bachrach and others said. And while CMS has allowed Arkansas and Iowa to use the Medicaid expansion money to expand private insurance coverage, approval for Pennsylvania might not be automatic.
That's because Pennsylvania's Medicaid coverage for adults is already managed by private companies and it can simply expand on that platform, said Joan Alker, the executive director of Georgetown University's Center for Children and Families, who has closely followed states' Medicaid expansion plans. Meanwhile, Corbett's proposal to expand private insurance coverage is not as clearly defined as Arkansas' and Iowa's, Alker said.
"The private coverage piece is vague, lacks clear objectives and is unwarranted," she said.
Lawyers with Community Legal Services, a Philadelphia public interest law center that advocates for the poor, say Corbett is asking CMS to waive Medicaid's appeals process, which guarantees benefits for enrollees while they fight to keep their eligibility, in favor of the commercial insurers' grievance and appeals processes. That, the lawyers said, violates enrollees' constitutional rights to due process.
"CMS can't waive the Constitution," said Community Legal Services lawyer Kristen Dama.
Other elements that push the boundaries of Medicaid — and thus would draw a hard look from CMS — include higher premiums for enrollees and taking away coverage from those who miss deadlines to pay premiums.
Accompanying Corbett's proposal is a request to pare the existing Medicaid program for adults, including limiting hospital admissions, medical supplies and radiology procedures such as MRIs, CT scans and X-rays. That, Alker said, has nothing to do with the purpose of a waiver, and it is possible CMS tells Corbett to request those changes separately.
Whatever happens, all four Democrats seeking to challenge Corbett in the Nov. 4 general election have pledged to tear out his plan and replace it with a straightforward Medicaid expansion, the step that 22 other states took.
Any decision in the Pennsylvania case will reverberate. Several other states — Utah, New Hampshire and Tennessee among them — are eyeing a waiver process.
CMS' policy is evolving as states try to tailor the program to add more personal responsibility for beneficiaries, said Matt Salo, the executive director of the Washington, D.C.-based National Association of Medicaid Directors. That has prompted CMS to bend in an effort to get more states into the Medicaid expansion program, he said.
"Can Pennsylvania expect to get everything it wants? No," Salo said. "Can it expect to get what other states have gotten? Yes. Can it expect to get a little bit more than other states? Maybe."
Still, if the White House thinks Corbett will lose in November — and his public approval rating isn't inspiring — that may stiffen CMS' stance.
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"Gubernatorial politics," Salo said, "are clearly important."
