Nebraska and the ACA’s Medicaid expansion

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Medicaid expansion in Nebraska

Nebraska’s Medicaid program was overhauled in 2016 as Heritage Health, which took effect January 1, 2017, combining all necessary care into one coordinated system, utilizing three managed care companies.

Medicaid expansion will take effect in Nebraska in 2019, under the terms of the ballot initiative that was approved by the state’s voters in the 2018 election. But until that’s implemented, eligibility guidelines are unchanged from 2013. Parents with minor children are eligible for Medicaid with a household income of up to 63 percent of the poverty level (that’s about $15,800 for a family of four in 2018), but non-disabled adults without dependent children are ineligible for Medicaid, regardless of how low their income is.

However, voters in Nebraska approved Initiative 427 in the November 2018 election, and 90,000 people in Nebraska are expected to become newly eligible for Medicaid coverage under the terms of the initiative.

Medicaid expansion: Voters say yes

Lawmakers in Nebraska have rejected Medicaid expansion for the last six years. So proponents of Medicaid expansion took the issue to the voters.

Nebraska State Senator Adam Morfeld (D, Lincoln) introduced Legislative Resolution 281CA, which called for a constitutional amendment to be on the ballot, declaring health care a right and expanding Medicaid in Nebraska. But that measure did not advance in the Health and Human Services Committee.

Instead, supporters began working on a ballot initiative that would propose a Medicaid expansion law, instead of a constitutional amendment (7 percent of voters have to sign the petition to get a proposed law on the ballot, as opposed to 10 percent for a constitutional amendment). Medicaid expansion proponents began collecting signatures on March 31. In order to get the initiative on the November 2018 ballot, supporters needed to gather 85,000 signatures by July 6, 2018.

More than enough signatures were gathered, and the Nebraska Secretary of State confirmed in late August that Medicaid expansion would be on the ballot in Nebraska in November 2018. And a judge rejected efforts by Nebraska GOP Senators who tried to block the ballot initiative based on “procedural, statutory and constitutional flaws.” Nebraska Initiative 427,  which passed with 53 percent of the vote, requires the state to expand Medicaid as called for in the ACA (ie, without a waiver proposal for any state-specific changes). According to the terms of the initiative, the state must submit an expansion plan to the federal government by April 1, 2019.

Maine voters approved Medicaid expansion with a ballot initiative in the November 2017 election. Under the terms of the ballot initiative, Medicaid expansion in Maine was supposed to take effect by July 2018, although the governor, who opposes Medicaid expansion, has been delaying the process (Maine’s Governor-elect will move forward with Medicaid expansion implementation as soon as possible in 2019). But in light of Maine’s success with a ballot measure, Medicaid expansion supporters in Utah, Idaho, and Nebraska all gathered enough signatures to get Medicaid expansion measures on their ballots this year, and the measures passed in all three states.

Private option expansion bill failed in 2016; another attempt at expansion failed in 2017

On January 19, 2016, Nebraska State Senator John McCollister (R, Omaha), introduced Legislative Bill 1032 in an effort to expand Medicaid in Nebraska. McCollister has been leading the push for Medicaid expansion in the state for almost a year, but his legislation failed to advance out of committee.

LB1032 would have been a privatized approach to Medicaid expansion, similar to the system Arkansas implemented in 2014, and New Hampshire implemented in 2016 (New Hampshire lawmakers are considering abandoning the private approach, however, and switching to Medicaid managed care). LB1032 also included optional education and job skills training for Medicaid enrollees, in an effort to help them transition to higher-paying jobs and away from public assistance programs like Medicaid.

In early discussions, Governor Ricketts reiterated his opposition to Medicaid expansion, including the privatized version proposed in LB1032. And conservative lawmakers were opposed to LB1032 as well, ultimately dooming it. The 2016 legislative session ended in Nebraska with no progress towards Medicaid expansion or closing the state’s coverage gap.

And in 2017, just before the start of the Trump Administration, Sen. Morfeld introduced LB441, which called, yet again, for Medicaid expansion in Nebraska. But a legislative committee decided to take no action on the bill in the spring of 2017, as the state waited to see what would happen in terms of health care reform at the federal level (at that point, ACA repeal bills were still very much under consideration in Congress, although they all ultimately failed later in 2017).

Previous efforts to expand Medicaid

Although Nebraska has not accepted Medicaid expansion yet, bills have been introduced in each of the last six sessions to try to move the state forward with Medicaid expansion.

In 2013, LB577, which would have created a modified Medicaid expansion program, was rejected by the legislature in Nebraska. A year later, the Wellness in Nebraska Act (LB887) was introduced in January 2014 by Senator Kathy Campbell, but it didn’t pass during the 2014 legislative session, and was indefinitely postponed in April 2014.

The Wellness in Nebraska Act would have expanded traditional Medicaid to people with incomes up to the poverty level (those who are currently in the coverage gap), and would have relied on federal Medicaid funding to purchase private coverage for people with incomes between 100 percent and 138 percent of poverty. Several states are using waivers to implement unique approaches to Medicaid expansion, and New Hampshire and Arkansas both use waivers purchasing private coverage for at least some Medicaid enrollees.

The Nebraska Hospital Association was very supportive of LB887, as they stand to lose about $1.3 billion over the next decade if declining federal reimbursement isn’t offset by Medicaid expansion.

In 2015, lawmakers introduced Legislative Bill 472 to expand Medicaid, but it did not pass out of committee. Also in 2015, two professors from the University of Nebraska-Kearney published the results of a study that found that expanding Medicaid would result in significant financial benefits for the state. After exhaustive study, the researchers concluded that expansion of Medicaid “passes a rigorous cost/benefit analysis.”

Senator McCollister found the results of the study compelling, and in May 2015, he introduced LR306, a bill to study possible ways that Medicaid expansion could be implemented in Nebraska.

In September and October 2015, a coalition of state lawmakers — led by McCollister — met to discuss possible avenues for expanding the state’s Medicaid program.

Governor Pete Ricketts continued to oppose Medicaid expansion, calling it too expensive and insisting that community health clinics are a better solution for Nebraska (despite the fact that they aren’t equipped to provide a full range of healthcare). But the U of N study found that if Nebraska had expanded Medicaid already, the state would have saved $3.5 million in the 2016 fiscal year. The savings increase in coming years, making continued resistance to Medicaid expansion a financially poor decision.

The current situation: Thousands in the coverage gap, with no realistic access to coverage

Because Nebraska has thus far rejected federal funding to expand its Medicaid program, eligibility rules in the state are unchanged from 2013. ACA premium subsidies for private plans are only available for people with household incomes between 100 percent and 400 percent of poverty level; there is no financial assistance for people living below the poverty line in states that have not expanded Medicaid.

In Nebraska, that means an estimated 16,000 people are in the coverage gap, with no access to Medicaid, and also no realistic access to private insurance, as they would have to pay the full premium themselves, with no subsidy to reduce the cost. Nebraska is one of 19 states that have not expanded Medicaid as of 2018 (if and when Maine expands coverage, that number will drop to 18 states).

Leaving money on the table

If Nebraska were to expand its Medicaid program, roughly 80,000 to 90,000 residents would gain coverage under the program over the next five years. By not expanding Medicaid, Nebraska is missing out on $3.1 billion in federal funding between 2013 and 2022. And Nebraska residents are paying federal tax dollars that are being used to fund Medicaid expansion in other states – to the tune of $3.3 billion over the next decade.

 

Who is eligible?

Because Nebraska has not expanded Medicaid, eligibility guidelines are the same as they were in 2013.  Non-disabled adults without children are ineligible for coverage, regardless of how low their income is.  Coverage is available for the following populations:

  • Parents with dependent children, if their household income doesn’t exceed 63 percent of poverty ($11,280 a year for a family of three).
  • Pregnant women with household income up to 199 percent of poverty.
  • Children with household income up to 218 percent of poverty.

How do I apply?

  • You can enroll online at HealthCare.gov at any time – Medicaid enrollment is available year-round.  You can also enroll by phone via the HealthCare.gov call center at 800-318-2596.
  • You can also enroll online at ACCESSNebraska at any time.
  • The Do I Qualify screening tool at ACCESSNebraska can help you determine which public programs you’re eligible for – you may be able to enroll in other benefits beyond Medicaid.

A net decrease in enrollment since 2013

By mid-April 2014, 9,879 Nebraska exchange applicants had enrolled in Medicaid or CHIP. They were already eligible based on the pre-2014 enrollment guidelines, but may not have known that Medicaid was available to them.

But from the fall of 2013 through July 2016, total net enrollment in Nebraska’s Medicaid program actually declined by 9,764 people, which amounted to a decrease of 4 percent. By the end of 2017, however, enrollment was back to nearly where it had been in 2013, with only 2,279 fewer enrollees in Medicaid/CHIP — a decrease of 1 percent since late 2013. Nebraska, Oklahoma, and Wyoming are the only states where Medicaid/CHIP enrollment declined between 2013 and the end of 2017.

New coordinated system has three managed care organizations

As of 2013, nearly 76 percent of Nebraska’s Medicaid enrollees were in managed care programs run by Aetna, AmeriHealth, and UnitedHealthcare. The state overhauled its Medicaid managed care system in 2016, and managed care contract bids were submitted by six carriers in early January.

The overhauled program is called Heritage Health, and it combines coverage (for Medicaid and CHIP) of physical health, behavioral health, and pharmacy care into one coordinated system. The new system took effect January 1, 2017. Three carriers were awarded contracts to serve as managed care plans under Heritage Health:

  •  Nebraska Total Care (Centene)
  • UnitedHealthcare Community Plan
  • Wellcare of Nebraska

As of July 2017, the Nebraska Department of Health and Human Services noted that by May 2017, all three managed care insurers were paying claims to providers within 15 days, more than meeting the state’s requirement.

Nebraska Medicaid history

Nebraska implemented Medicaid in July 1966, just a few months after the first wave of states did so in January of that year.

In 1986, Medicaid was 8.6 percent of Nebraska’s general fund appropriations. By 2006/07, it had grown to 17.8 percent. This is similar to the increases other states have seen, and reflects a similar trajectory to the overall increase in healthcare spending in the US as a percentage of GDP.  But while Medicaid expenses grew at a rate of about 11 percent over those two decades, general fund revenue grew by only 6.9 percent. Officials in Nebraska have highlighted the financial implications of Medicaid spending in this report, and are calling for reform that would help the state hold down costs going forward.

The federal match rate for Medicaid (the portion that the federal government pays, in addition to what the state pays) is tied to the per capita income in the state, and rising incomes in Nebraska mean that the federal match rate for Medicaid costs decreased from 53.27 percent to 51.16 percent in 2016.

This was the lowest federal match rate in the history of Nebraska’s Medicaid program, and the impending decrease led the Nebraska Department of Health and Human Services to request $76 million from the legislature in October 2014, to cover the anticipated budget shortfall over the upcoming two fiscal years.

By fiscal year 2018, Nebraska’s federal match rate had increased slightly, to 52.55 percent.


Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.