Congress targets unpaid care pools in non-expanded states

Congressional Democrats are renewing their struggle with states such as Texas and Florida that have not yet extended Medicaid to low-income adults, with the goal of one of their main sources of funding for hospitals: Free nursing pool.

President Joe Biden’s 1.75 trillion USD domestic policy packageThe House of Representatives may vote as soon as this week to restrict federal unpaid medical payments to states that have not expanded the Medicaid program.

Democrats and experts believe that state leaders who want to help hospitals provide high levels of unpaid care should Expansion of Medicaid Like the other 38 states, it covers more low-income adults.

Eliot Fishman, senior director of health policy at Families USA, a consumer rights organization in Washington, said: “It’s not a good way to spend federal funds to keep people out of insurance and then pay for potentially preventable hospital services.”

“It is very likely that they were hospitalized because they did not have medical insurance,” said Fishman, who worked on the Medicare and Medicaid Service Center’s Medicaid exemption issue from 2013 to 2017.

These pools of funds to help certain states pay for unpaid medical care and low Medicaid expenses have existed in some form for several years, but after the passage of the “Affordable Care Act” in 2010, they fell into the politics of Medicaid expansion.

Twelve states have not expanded the Medicaid program, but only four states Free nursing pool: Texas, Florida, Tennessee and Kansas.

Provisions in the domestic policy package-dubbed the “Better Rebuild Act” by the government-will limit the payment of unpaid care pool fees to states to cover 138% to 100% of the federal poor who are eligible for Medicaid The uninsured persons provide it if their country expands it.

The proposed legislation does not prevent states from using these pools of funds to pay for other unpaid care for insufficient Medicaid or other uninsured individuals.

The American Hospital Association and the American Hospital Federation hope to remove the provision for unpaid care pools from the bill, believing that this will harm the safety net of hospitals in these four non-expanding states.They also urged Congress to adopt Terms Reduce disproportionate hospital payments by 12.5% ??in non-expanded states.

Cuts will be part offset-At least temporarily-by increasing ACA subsidies for 2.2 million people in the non-expanding state coverage gap. But these subsidies need to be reauthorized by Congress after four years, and it is not certain that this will happen, or that the Democrats will control Congress by then. At the same time, Republicans in Congress have no interest in closing the expansion gap or supporting the ACA.

Joan Alker, executive director and co-founder of the Georgetown University Center for Children and Families, said that despite this, swimming pools have never been a permanent solution for unpaid care, especially in the state that received the funding without expanding Medicaid programs. in the case of.

Each state must obtain approval from the CMS for the funding pool under the 1115 Medicaid exemption, and the federal government must match the funding provided by each state. The exemption aims to test innovative ways of providing healthcare through Medicaid.

“This is by no means a guaranteed way to provide funding for any state,” she said.

“If states are concerned about the unpaid care their providers are experiencing because of the high uninsured rate in these states, then it is wise to expand the Medicaid program.”

Florida Texas, the state with the highest uninsured rate in the country, is the biggest beneficiary of this funding, and firmly refuses to expand the Medicaid program, even though Congress provides them with more financial incentives.

It is not clear how much the proposal reduces payments to the four non-expanding states-these calculations will be left to the Medicare and Medicaid Services Center.

Texas has now been approved to pay up to $4 billion in unpaid care funding per year until September 30 next year, while Florida can pay up to $1.5 billion annually until June 30 next year. State Health Access Data Assistance Center.

Tennessee is authorized to spend US$627 million per year, while Kansas can spend US$51 million per year.

Three states with expanded Medicaid programs, including California, also have smaller pools of unpaid care that are not affected by the proposal.

According to data from the Medicaid and the CHIP Payment and Use Committee, overall, in the medical subsidies paid to hospitals in fiscal year 2019, the unpaid medical pool payments accounted for about 4% of the Medicaid.

But the reduction ultimately means that if the state continues to resist the expansion of Medicaid, or if subsidies for people in the coverage gap are allowed to expire, hospitals will receive less help with uncompensated medical expenses.

Some congressional Democrats from Texas and other non-expanding states said they are concerned about the transition period between getting people to sign up for the ACA program and changing the funding pool. Starting in 2022, people in coverage can receive ACA subsidies to purchase plans in the market. Regulations on unpaid care pools will take effect in 2023.

Rep. Jim Cooper (D-Tenn.) and 19 other lawmakers wrote in a letter: “The problem is that using this temporary coverage solution to cover most uninsured people in non-expanded states will require data. Months or even years.” Earlier this month, Democratic leaders in the House of Representatives and Senate.

“This is a matter of registration rate and time. Once hospitals get better reimbursement from private insurance rates, they will undoubtedly be more stable, but the transition can be catastrophic,” the letter said.

Roberto Haddad, vice president of government affairs and policy at the Renaissance Medical System Doctors Hospital in Edinburgh, Texas, said he believes the clause will make it unlikely that states will expand Medicaid.

“States have all the opportunities and incentives to expand the Medicaid program. Although this is absolutely meaningful at the policy level and economic level, and most importantly at the humanitarian level, they have not done so because politics has become deeply rooted in the hearts of the people,” he said . Said.

“And I think the provisions of this bill will only make this situation worse.”

Advocates and hospitals have pushed Congress to pass a permanent solution Coverage gap problem But due to cost issues raised by moderate Democrats in the Senate, it was eventually removed from the domestic policy package.

Since then, the unpaid care pool has been linked to the politics of Medicaid expansion 2015, When the Obama administration suggested Considering how many people will receive insurance if Florida expands its Medicaid program, payments to Florida are reduced by 75%.

In the last few days of the Trump administration, HHS approved the renewal of Florida’s unpaid care exemption. Texas And Tennessee for ten years. According to the renewal, Texas and Florida will receive more funding.

The Biden administration objected to the Trump administration’s procedures used to approve the Texas exemption – no notice and comment period – and Renegotiation It has terms with the state, but it did not specifically comment on the policy that allows pool funds to be used to cover the gap population.

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