Sleepless Nights In Spite of Medicaid and Marketplace Coverage Gains Stemming from the ACA

Since the passage of the Affordable Care Act (ACA) in 2010, remarkable strides have been made in expanding health coverage for more Americans. This progress has not been confined to states with long-standing political support for public health coverage. Coverage gains have also occurred in places such as Arizona that have both a large uninsured population as well as a history of enacting public policies that limit people from seeking and retaining public health coverage.

I work for a public foundation, St. Luke’s Health Initiatives, based in Arizona. Thanks to the leadership of former Gov. Jan Brewer (R) and the business community, Arizona became one of the first states to agree to expand its Medicaid program after the US Supreme Court, back in 2012, made it an option for states. Because of this early policy victory and concerted efforts by a community-based coalition of more than 800 partners, more than 500,000 Arizonans have enrolled in health coverage through expanded Medicaid or the federally facilitated Marketplace to date.

While these accomplishments should be celebrated, I am fearful that states such as Arizona may lose their momentum to build upon or even retain their coverage gains.

This is what keeps me up at night:

• King v. Burwell—Many of us living in states with a federally facilitated exchange are worried about the outcome of the US Supreme Court decision this summer on whether there will be continued subsidies for health coverage. In states such as Arizona, it would be a heavy policy “lift” to find a way to provide affordable health care coverage to the 160,000 Arizonans who potentially could lose their subsidies for affordable health coverage purchased through the Marketplace.
• Adverse Court Decision on Medicaid Expansion—Arizona was able to expand its Medicaid program, in part, because of an agreement by hospitals to pay the state costs associated with expansion through a hospital assessment. This financing mechanism is now being called into question by thirty-six lawmakers who are suing, claiming that the assessment required a two-thirds vote of the legislature (required of any tax), rather than a majority vote of the legislature (a majority was enough to pass the legislation that expanded Medicaid in Arizona). An adverse decision by an Arizona court could result in nearly 300,000 Arizonans losing health coverage. The decision will likely come out this summer. While it is possible that the community could rally to reinstate Medicaid expansion through some effort such as a ballot initiative, such an effort would not be easy to accomplish and it would be extremely costly.
• Medicaid Waivers—Arizona’s legislature recently passed a bill requiring our state’s Medicaid program to request permission from the federal government (through changes to our Medicaid waiver) to impose time limitations on how long someone could receive Medicaid, and tie receipt of Medicaid coverage to work requirements. These and other measures—if approved by this or future federal administrators—could undermine the important safety net that Medicaid plays for many vulnerable Arizonans. Native American leaders have already noted to the Centers for Medicare and Medicaid Services (CMS) that such waiver changes could harm native communities—unemployment rates for several tribes have hovered at more than 30 percent.
• Decreased Philanthropic Support—In many poorer, younger states such as Arizona, philanthropic resources are very limited. While foundations such as the one that I represent have invested significantly in outreach and enrollment assistance efforts locally, we very much depend on national funders to help support such work. Philanthropic resources do not run deep in states such as ours. Recent retrenchment by national funders in supporting this work could stymie our momentum and diminish our ability to fully realize potential coverage gains.

While it is important to celebrate the successes that have been achieved to date, foundations, advocates and policy makers need to remember that while it took many years for federal health reform to pass, it will take many years for the federal law to be successfully implemented, with many bumps and challenges along the way. We have made tremendous progress in covering more Americans. Let’s not lose our collective resolve to see this effort of expanding affordable coverage for all Americans to the finish.