Perhaps the best information on the costs -- though not necessarily the benefits -- of Medicaid expansion in Alaska under the Affordable Care Act are contained in a report prepared under a state contract by the Lewin Group of Falls Church, Va.
The finished report was delivered to the Alaska Department of Health and Social Services April 12. Though it was prepared with $80,000 in public funds, was designed to inform public policy, is owned by the state, contains no reference to national security, doesn't mention the names of undercover officers or informants, and doesn't reference intelligence gathering techniques, it remains virtually a state secret.
The Parnell administration has refused at least eight requests from legislators, the media and nonprofits for a copy of the Lewin report, saying it is nondisclosable because it forms part of the executive branch's "deliberative process."
What is the administration deliberating? Whether to expand Medicaid to eliminate the "coverage gap" for Alaskans too poor to afford medical insurance premiums but who don't qualify for either the federal tax subsidy under Obamacare or for Medicaid with its current restrictions. More than 40,000 uninsured Alaskans are believed to be in that group.
Parnell rejected Medicaid expansion last year but said he is considering including it in the budget he submits to the Legislature in December. To get full reimbursement from the federal government and to allow Alaskans the best coverage, it would have to be in effect Jan. 1.
As passed by Congress, the Affordable Care Act required states to change the way they qualify people for Medicaid. For instance, Alaska and most states don't allow single people, or married couples without children, to get Medicaid.
Obamacare changed that. Everyone whose income was up to 138 percent of the federal poverty level -- $19,803 for a single person, $40,627 for a family of four -- would qualify unless they were in the United States illegally or were recent documented immigrants.
For people with a little more money, Obamacare provided subsidies based on income for private insurance premiums. Because Congress assumed that the states would expand Medicaid for their poorest residents, it only created subsidies for people whose incomes were above the poverty level.
To compensate for the federal Medicaid mandate, Congress gave states 100 percent of their costs for new enrollees from 2014 through 2016. Starting in 2017, reimbursements would trimmed until they were down to 90 percent in 2020.
The U.S. Supreme Court ruled in 2012 that key provisions of the Affordable Care Act were constitutional, but also ruled that Congress couldn't require states to expand Medicaid coverage. About 25 states, including Alaska, have so far declined the offer.
What would be the impact on Alaska of Medicaid expansion?
According to its contract with the Lewin Group, the state only asked the experts there to calculate the costs of the new enrollees, according to a copy of the contract obtained by legislators. The consultants were asked to prepare cost estimates by category of recipient, and were even asked to predict how many Alaskans would deliberately reduce their incomes to qualify.
The state's contract language used what some might consider a disparaging term for low-income Alaskans -- "woodwork population" -- who currently qualify for Medicaid but haven't applied. They would, the contract suggested, come out of the woodwork and apply for Medicaid to avoid the penalties in Obamacare for not having insurance.
The contract document asks the consultants to look for only one benefit -- reduced costs of other state programs that could offset increased Medicaid spending.
Other groups have cited additional benefits of Medicaid expansion. The Alaska Native Tribal Health Consortium, an advocate for the Affordable Care Act, cited the healthcare benefits to the 40,000 Alaskans who could obtain Medicaid for the first time. Members of the Alaska State Chamber of Commerce, in calling on the state to approve the expansion, cited increased economic activity, lower rates of patient nonpayment for hospital visits and other medical services, and increased wellness among Alaskans who would have regular primary care for the first time.
Though the Lewin Group information isn't available, other experts have been providing information Medicaid expansion. The Native Tribal Health Consortium produced a 38-page study on the issue in February, and health-care experts at the Kaiser Family Foundation have been talking to reporters about expansion, including in on-line seminars. Here are some of their points:
• 41,500 uninsured Alaska residents, including 15,700 Alaska Natives, would become eligible for Medicaid if the expansion is approved (ANTHC).
• Alaska's statewide mortality rate would decline significantly -- one prevented death per year for each 176 newly covered adults (ANTHC).
• About 3,500 new jobs would be created by 2017 through expansion (ANTHC).
• Between 2014 and 2020, the state would spend $90.7 million on expansion, while receiving $1.1 billion federal funds. Savings in other programs would offset the state contribution by at least $67.3 million. Over the first five years, the offsets would actually be greater than the expenditures on Medicaid (ANTHC).
• Some of the states that established their own on-line insurance marketplaces using federal funds have been successfully enrolling people for both Medicaid and private insurance even as states that opted to rely on the federal website, like Alaska, have been waiting for healthcare.gov to be improved. The states with well-functioning websites include Washington, Minnesota, Oregon and Kentucky (Kaiser Family Foundation).
• Nationally, Medicaid enrollment could increase by 21 million by 2022 if all states move forward with expansion. Increased covered would mean better access to health-care services (Kaiser Family Foundation).
• The Supreme Court decision making participation voluntary also means that states that agree to expand Medicaid could change their mind at a later date and withdraw, for instance if the federal government reneges on its reimbursement promise. The U.S. Health and Human Services says there's no deadline for states to decide to expand Medicaid, though they would only get 100 percent reimbursement for their new costs for the years 2014 through 2016 (Kaiser Family Foundation).
• When Medicaid started as part of President Lyndon Johnson's Great Society in 1965, only 26 states decided to participate, a number "strikingly similar" to the current situation involving Medicaid expansion, Kaiser Family Foundation's Robin Rudowitz told reporters last week. By 1970, 49 states had signed up to Medicaid, she said.
• While tax credits for insurance premiums will be available starting in 2014 for people at 100 percent or more of the federal poverty level, as a practical matter, most uninsured will not be able to afford health coverage even with subsidies unless they were above the 138 percent level, which is why that number was targeted in Medicaid expansion (Kaiser Family Foundation).
• Several states that initially were lukewarm to expansion appear to be reconsidering, like New Hampshire, whose governor has called a special session for the state legislature in November on the issue (Kaiser Family Foundation).
• The federal government has said it wouldn't give the 100 reimbursement to a state that made only a partial expansion, but is considering some creative alternatives as experiments. Arkansas has gotten approval for paying the insurance premiums of people in its expanded program instead of paying their medical bills (Kaiser Family Foundation).
• Because more qualify for Medicaid here, Alaska's 67 percent of uninsured poor in the "coverage gap" -- below the poverty level but ineligible for Medicaid -- is the smallest percentage among the 25 states not moving forward with expansion. The national average is 86 percent or 5 million people, with three states -- Idaho, North Carolina and Texas -- at 91 percent (Kaiser Family Foundation).
Reach Richard Mauer at firstname.lastname@example.org or 257-4345.