Analysis Health Systems

Don’t Call Pennsylvania’s Proposed Medicaid Plan an ‘Expansion’

Tara Murtha

In short, Healthy PA would extend some coverage to Pennsylvanians in the health-care gap, but it doesn’t expand the Medicaid program, and would reduce benefits of current enrollees.

Under the Affordable Care Act, states are encouraged to expand access to Medicaid coverage, with the federal government picking up the tab through 2016 and then paying no less than 90 percent on a permanent basis.

Most of the 26 states that rejected the expansion are “more conservative states in the South, Midwest and northern Rocky Mountains that voted against Obama,” the Associated Press reports. Pennsylvania is a geographic and political outlier; rather than accept expansion like every state it borders, Gov. Corbett submitted a 97-page waiver requesting the federal government let the state use those funds to help uninsured and underinsured low-income residents purchase privatized Medicaid insurance plans. The proposal is clearly conditional: The state will accept the federal dollars, not if but “when” the federal government accepts its proposal, which includes requiring enrollees to pay monthly premiums—and lose coverage if they miss payments—as well as prove they are searching for full-time work. (The majority of people on Medicaid in Pennsylvania already work full-time or live with someone who works full-time.)

In short, it’s a Frankenstein plan. The state is calling it “Healthy PA,” which is a laudable goal, especially considering the state earned an overall health ranking of 29 in a recent nationwide analysis, and Philadelphia in particular is suffering a dire crisis in maternal and infant health.

Corbett is also calling his plan “reform,” sending a signal through the Obamacare fog to the conservative base that he’s still fighting the health-care law he unsuccessfully attempted to overturn while attorney general.

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The word reform, however, connotes improvement, and almost across the board health policy experts say the plan is not actually going to improve access to health care for the working poor of Pennsylvania.

News outlets can’t seem to agree on what words to use when describing the policy. Some use the relatively value-free termalternative.” Other reports have used the phrases “hybrid Medicaid expansion,” “variation,” and “fake Medicaid expansion plan.” And some default to the “expansion” language since that it is, after all, what we’re talking about. Or it was what we were talking about initially.

Advocates for low-income Pennsylvanians, however, say the most accurate term is “Medicaid cuts.”

“It’s not so much Medicaid expansion but Medicaid cuts,” said Kristin Dama, a staff attorney at Community Legal Services (CLS) of Philadelphia, a nonprofit that offers legal help to low-income clients.

“Pennsylvania is one of the first states, if not the first, to take the Medicaid expansion that’s supposed to be an expansion and use it, and use the language of expansion, as a vehicle for retraction of coverage,” she told Rewire. Dama describes proposed benefit cuts to existing Medicaid enrollees as “significant and profound.”

Under the current Medicaid plan, radiology, lab work, in-patient hospital care, “durable medical equipment and supplies,” in-patient psychiatric hospital stays, and in-patient drug and alcohol stays have no spending limit. Under the proposed plans, these services have spending caps, according to an analysis provided by CLS.

The spending limits are staggered on a two-tier system of “low-risk” and “high-risk.” For example, a new spending limit on lab work in the new low-risk plan would be $250 per year, while the new limit for current Medicaid enrollees rolled into the high-risk plan would be $350 per year.

The state’s current Medicaid program covers 2.2 million people—1.1 million children, 379,000 parents, 250,000 seniors, 515,000 people with disabilities, and 72,000 chronically ill adults—according to the Pennsylvania Budget & Policy Center, which has called the cuts “severe.”

From the group’s analysis: “It seems clear that the Corbett administration is using the Medicaid expansion as leverage to press for significant reductions to the health care program that has served the state’s most vulnerable citizens for more than 50 years.”

In addition to capping benefits, Healthy PA retracts Medicaid coverage by installing obstacles such as monthly premiums and a work-search requirement. With some exceptions, the plan proposes premiums for people earning more than 50 percent of the federal poverty line—even though federal officials rejected a similar proposal in Iowa.

“The bigger issue in calling it an ‘expansion’ is that it is not a viable proposal to expand Medicaid, because it violates Medicaid law for the new beneficiaries and puts up so many roadblocks to coverage that it wouldn’t work,” said Joan Alker, executive director of the Center for Children and Families at the Georgetown Health Policy Institute. “And while he is in the neighborhood, the governor is cutting benefits for current eligibles.”

It’s not just policy experts saying not to call it an expansion. From an eight-page review of the plan published by the Department of Public Welfare: “This would not be an expansion of Medicaid.”

In short, Healthy PA would extend some coverage to Pennsylvanians in the gap, but it doesn’t expand the Medicaid program, and it would reduce benefits of current enrollees.

In the improbable case of the plan being passed as proposed, the implementation wish-date is 2015. In the meantime, how many people are left hanging in the gap? More than half a million. They earn too much money to qualify for current Medicaid (for parents, that equates to more than 23 percent of the federal poverty line), but not enough to receive a tax subsidy to purchase insurance on the exchange (above 100 percent of the federal poverty line).

An example provided in an analysis published by the Pennsylvania Health Law Project and Georgetown University Health Policy Institute Center for Children and Families illuminates the absurdity of this gap: Parents in a family of four with a household income of $75,000 per year will receive financial support to buy health insurance, but the same size family with a household income of $23,000 will receive no financial support.

The proposal is currently in the feedback phase. Open hearings are scheduled around the state through next week.

Analysis Abortion

Legislators Have Introduced 445 Provisions to Restrict Abortion So Far This Year

Elizabeth Nash & Rachel Benson Gold

So far this year, legislators have introduced 1,256 provisions relating to sexual and reproductive health and rights. However, states have also enacted 22 measures this year designed to expand access to reproductive health services or protect reproductive rights.

So far this year, legislators have introduced 1,256 provisions relating to sexual and reproductive health and rights. Of these, 35 percent (445 provisions) sought to restrict access to abortion services. By midyear, 17 states had passed 46 new abortion restrictions.

Including these new restrictions, states have adopted 334 abortion restrictions since 2010, constituting 30 percent of all abortion restrictions enacted by states since the U.S. Supreme Court decision in Roe v. Wade in 1973. However, states have also enacted 22 measures this year designed to expand access to reproductive health services or protect reproductive rights.

Mid year state restrictions

 

Signs of Progress

The first half of the year ended on a high note, with the U.S. Supreme Court handing down the most significant abortion decision in a generation. The Court’s ruling in Whole Woman’s Health v. Hellerstedt struck down abortion restrictions in Texas requiring abortion facilities in the state to convert to the equivalent of ambulatory surgical centers and mandating that abortion providers have admitting privileges at a local hospital; these two restrictions had greatly diminished access to services throughout the state (see Lessons from Texas: Widespread Consequences of Assaults on Abortion Access). Five other states (Michigan, Missouri, Pennsylvania, Tennessee, and Virginia) have similar facility requirements, and the Texas decision makes it less likely that these laws would be able to withstand judicial scrutiny (see Targeted Regulation of Abortion Providers). Nineteen other states have abortion facility requirements that are less onerous than the ones in Texas; the fate of these laws in the wake of the Court’s decision remains unclear. 

Ten states in addition to Texas had adopted hospital admitting privileges requirements. The day after handing down the Texas decision, the Court declined to review lower court decisions that have kept such requirements in Mississippi and Wisconsin from going into effect, and Alabama Gov. Robert Bentley (R) announced that he would not enforce the state’s law. As a result of separate litigation, enforcement of admitting privileges requirements in Kansas, Louisiana, and Oklahoma is currently blocked. That leaves admitting privileges in effect in Missouri, North Dakota, Tennessee and Utah; as with facility requirements, the Texas decision will clearly make it harder for these laws to survive if challenged.

More broadly, the Court’s decision clarified the legal standard for evaluating abortion restrictions. In its 1992 decision in Planned Parenthood of Southeastern Pennsylvania v. Casey, the Court had said that abortion restrictions could not impose an undue burden on a woman seeking to terminate her pregnancy. In Whole Woman’s Health, the Court stressed the importance of using evidence to evaluate the extent to which an abortion restriction imposes a burden on women, and made clear that a restriction’s burdens cannot outweigh its benefits, an analysis that will give the Texas decision a reach well beyond the specific restrictions at issue in the case.

As important as the Whole Woman’s Health decision is and will be going forward, it is far from the only good news so far this year. Legislators in 19 states introduced a bevy of measures aimed at expanding insurance coverage for contraceptive services. In 13 of these states, the proposed measures seek to bolster the existing federal contraceptive coverage requirement by, for example, requiring coverage of all U.S. Food and Drug Administration approved methods and banning the use of techniques such as medical management and prior authorization, through which insurers may limit coverage. But some proposals go further and plow new ground by mandating coverage of sterilization (generally for both men and women), allowing a woman to obtain an extended supply of her contraceptive method (generally up to 12 months), and/or requiring that insurance cover over-the-counter contraceptive methods. By July 1, both Maryland and Vermont had enacted comprehensive measures, and similar legislation was pending before Illinois Gov. Bruce Rauner (R). And, in early July, Hawaii Gov. David Ige (D) signed a measure into law allowing women to obtain a year’s supply of their contraceptive method.

071midyearstatecoveragetable

But the Assault Continues

Even as these positive developments unfolded, the long-standing assault on sexual and reproductive health and rights continued apace. Much of this attention focused on the release a year ago of a string of deceptively edited videos designed to discredit Planned Parenthood. The campaign these videos spawned initially focused on defunding Planned Parenthood and has grown into an effort to defund family planning providers more broadly, especially those who have any connection to abortion services. Since last July, 24 states have moved to restrict eligibility for funding in several ways:

  • Seventeen states have moved to limit family planning providers’ eligibility for reimbursement under Medicaid, the program that accounts for about three-fourths of all public dollars spent on family planning. In some cases, states have tried to exclude Planned Parenthood entirely from such funding. These attacks have come via both administrative and legislative means. For instance, the Florida legislature included a defunding provision in an omnibus abortion bill passed in March. As the controversy grew, the Centers for Medicare and Medicaid Services, the federal agency that administers Medicaid, sent a letter to state officials reiterating that federal law prohibits them from discriminating against family planning providers because they either offer abortion services or are affiliated with an abortion provider (see CMS Provides New Clarity For Family Planning Under Medicaid). Most of these state attempts have been blocked through legal challenges. However, a funding ban went into effect in Mississippi on July 1, and similar measures are awaiting implementation in three other states.
  • Fourteen states have moved to restrict family planning funds controlled by the state, with laws enacted in four states. The law in Kansas limits funding to publicly run programs, while the law in Louisiana bars funding to providers who are associated with abortion services. A law enacted in Wisconsin directs the state to apply for federal Title X funding and specifies that if this funding is obtained, it may not be distributed to family planning providers affiliated with abortion services. (In 2015, New Hampshire moved to deny Title X funds to Planned Parenthood affiliates; the state reversed the decision in 2016.) Finally, the budget adopted in Michigan reenacts a provision that bars the allocation of family planning funds to organizations associated with abortion. Notably, however, Virginia Gov. Terry McAuliffe (D) vetoed a similar measure.
  • Ten states have attempted to bar family planning providers’ eligibility for related funding, including monies for sexually transmitted infection testing and treatment, prevention of interpersonal violence, and prevention of breast and cervical cancer. In three of these states, the bans are the result of legislative action; in Utah, the ban resulted from action by the governor. Such a ban is in effect in North Carolina; the Louisiana measure is set to go into effect in August. Implementation of bans in Ohio and Utah has been blocked as a result of legal action.

071midyearstateeligibilitytable

The first half of 2016 was also noteworthy for a raft of attempts to ban some or all abortions. These measures fell into four distinct categories:

  • By the end of June, four states enacted legislation to ban the most common method used to perform abortions during the second trimester. The Mississippi and West Virginia laws are in effect; the other two have been challenged in court. (Similar provisions enacted last year in Kansas and Oklahoma are also blocked pending legal action.)
  • South Carolina and North Dakota both enacted measures banning abortion at or beyond 20 weeks post-fertilization, which is equivalent to 22 weeks after the woman’s last menstrual period. This brings to 16 the number of states with these laws in effect (see State Policies on Later Abortions).
  • Indiana and Louisiana adopted provisions banning abortions under specific circumstances. The Louisiana law banned abortions at or after 20 weeks post-fertilization in cases of diagnosed genetic anomaly; the law is slated to go into effect on August 1. Indiana adopted a groundbreaking measure to ban abortion for purposes of race or sex selection, in cases of a genetic anomaly, or because of the fetus’ “color, national origin, or ancestry”; enforcement of the measure is blocked pending the outcome of a legal challenge.
  • Oklahoma Gov. Mary Fallin (R) vetoed a sweeping measure that would have banned all abortions except those necessary to protect the woman’s life.

071midyearstateabortionstable

In addition, 14 states (Alaska, Arizona, Florida, Georgia, Idaho, Indiana, Iowa, Kentucky, Louisiana, Maryland, South Carolina, South Dakota, Tennessee and Utah) enacted other types of abortion restrictions during the first half of the year, including measures to impose or extend waiting periods, restrict access to medication abortion, and establish regulations on abortion clinics.

Zohra Ansari-Thomas, Olivia Cappello, and Lizamarie Mohammed all contributed to this analysis.

News Abortion

Pennsylvania’s TRAP Law Could Be the Next to Go Down

Teddy Wilson

The Democrats' bill would repeal language from a measure that targets abortion clinics, forcing them to meet the standards of ambulatory surgical facilities.

A Pennsylvania lawmaker on Wednesday introduced a bill that would repeal a state law requiring abortion clinics to meet the standards of ambulatory surgical facilities (ASF). The bill comes in response to the U.S. Supreme Court’s ruling striking down a similar provision in Texas’ anti-choice omnibus law known as HB 2.

A similar so-called targeted regulation of abortion providers (TRAP) law was passed in Pennsylvania in 2011 with bipartisan majorities in both the house and state senate, and was signed into law by former Gov. Tom Corbett (R).

SB 1350, sponsored by Sen. Daylin Leach (D-Montgomery) would repeal language from Act 122 that requires abortion clinics to meet ASF regulations. The text of the bill has not yet been posted on the state’s legislative website.

The bill is co-sponsored by state Sens. Art Haywood (D-Philadelphia), Larry Farnese (D-Philadelphia), and Judy Schwank (D-Berks).

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Leach said in a statement that there has been a “nationwide attack on patients and their doctors,” but that the Supreme Court’s ruling upholds the constitutionally protected right to terminate a pregnancy.

“Abortion is a legal, Constitutionally-protected right that should be available to all women,” Leach said. “Every member of the Pennsylvania General Assembly swore an oath to support, obey and defend the Constitution of the United States, so we must act swiftly to repeal this unconstitutional requirement.”

TRAP laws, which single out abortion clinics and providers and subject them to regulations that are more stringent than those applied to medical clinics, have been passed in several states in recent years.

However, the Supreme Court’s ruling in Whole Woman’s Health v. Hellerstedt that struck down two of the provisions in HB 2 has already had ramifications on similar laws passed in other states with GOP-held legislatures.

The Supreme Court blocked similar anti-choice laws in Wisconsin and Mississippi, and Alabama’s attorney general announced he would drop an appeal to a legal challenge of a similar law.