Why Governor Reynolds is wrong

If the Governor cannot speak for the people of Iowa, who will do so?

As it has become clear that Iowa state leaders need to be more engaged publicly on the national health care debate, it was surprising to see Governor Kim Reynolds’ take on it.

“I’m focused on the things I can control.”

Well, if that is the standard for where the Governor should speak up, lock the office door and throw away the key. That’s not the way government works — or is supposed to work — in our American and Iowa tradition.

The Governor in our system has an important and powerful role, but rarely a controlling one.

What the Governor is not acknowledging, though she surely knows to be the case, is that her position is perhaps the best pulpit in the state of Iowa for speaking up on behalf of Iowans, to our elected representatives in the House and Senate in Washington, and to the President of the United States.

If she cannot speak for the people of Iowa, who will do so?

What is clear from the debate thus far in Washington is that more than 200,000 Iowans will lose health insurance if the current Affordable Care Act is repealed without a meaningful replacement.

In fact, the latest estimate from the Urban Institute finds 229,000 fewer Iowans would be insured in 2022 than if the ACA were kept in place — but the state would spend $29 million more as federal spending dropped by 28 percent.

The Governor’s comments to reporters repeated inaccurate talking points about ACA, avoiding both the state’s own role in undermining the individual insurance marketplace, and the principal way Iowans would lose insurance: the loss of the Medicaid expansion. That one piece of the ACA covers 150,000 Iowans now and is projected to grow to 177,000 in two years, but goes away under the Senate and House plans.

So, whether Governor Reynolds likes it or not, what is now a federal issue will become a state issue.

Right now, the things she has more direct influence upon are state budget choices, many of which already are difficult.

Imagine how much more difficult those choices become with 200,000 more people uninsured. What will the state do to make up for it? What budget control — or families’ control over their health care options — would be lost? Some members of the Legislature already are calling for a state-run program to step into the void.

If Governor Reynolds is uncomfortable with any of these possibilities she could call her friends Senator Grassley and Senator Ernst, or gather the microphones and cameras and raise awareness about the stakes for all Iowans.

Again, there are members of the Legislature weighing in on that score as well. Perhaps they recognize that persuasion, and pushing for a critical mass of support behind an idea, is where “control” emerges.

 

owen-2013-57Mike Owen, executive director of the Iowa Policy Project

mikeowen@iowapolicyproject.org

 

Toxic blooms for Iowa waters

Iowa’s water-quality issues are likely to become more severe without well-funded mandates that are enacted and enforced.

The Iowa Environmental Council (IEC) recently reported on the first toxic algal blooms of the summer beach season in Iowa. Two state park beaches posted swimming advisories warning people to stay out of the water because of the presence of high levels of microcystin. Microcystin is a toxin produced by blue-green algae, also known as cyanobacteria, that can cause health issues, particularly in children and pets.

As summer water temperatures climb, these closures and warnings will become more commonplace. The Iowa Policy Project first published a report on cyanobacteria in 2009 — a year with only one swimming advisory. The advisories have increased each year since and last year there were 37. (IEC has compiled a history of warnings.)

Cyanobacteria quickly multiply into high-density blooms in the presence of excess nutrients in the water. Several research reports by the Iowa Policy Project (links below) concluded that the most significant contributing factor of nutrients in the Mississippi River Basin is from agricultural runoff. Algal blooms have the potential to not only restrict recreational activities in our waterways, but to obstruct access to clean drinking water. This happened most notably in 2014 when a water treatment plant in Toledo, Ohio, warned its 500,000 customers not to use water from the tap because algae blooms surrounded water intakes at its Lake Erie source. The catastrophic algal bloom prompted the mayor to declare a state of emergency, as the city was forced to find alternative sources of drinking water.

Clean drinking water in Iowa is already threatened because of high nutrient concentrations in our waterways. The recent Des Moines Water Works (DMWW) lawsuit against three counties in north central Iowa highlighted this very problem. The DMWW must spend increasing sums to remove nutrients from the water obtained from the Raccoon and Des Moines rivers — so much it will now build a new nitrate removal facility. The nitrate present in these source rivers is primarily from agricultural runoff coming from the three counties named in the suit.

The magnitude of Iowa’s water quality issues cannot be overstated and the data we have show that these issues are only likely to deepen in severity without well-funded mandates for water quality that not only are enacted, but enforced. Voluntary conservation measures will not clean up our lakes, beaches, rivers and drinking water sources. If Iowa legislators are serious about luring businesses, jobs and families to this state, then it is time to make sure state revenues can support the protection of the very resource that supports our quality of life.

Sarah Garvin, research associate for the Iowa Policy Project
sgarvin@iowapolicyproject.org

 

 

Related IPP Reports:

Scum in Iowa’s Water: Dealing with the Impact of Excess Nutrients,” December 2009, Andrea Heffernan and Teresa Galluzzo

Solution to Pollution: It Starts on the Farm,” September 2010, Andrea Heffernan, Teresa Galluzzo and Will Hoyer

A Threat Unmet: Why Iowa’s Nutrient Reduction Strategy Falls Short Against Water Pollution,” July 2014, David Osterberg and Aaron Kline

Saving Resources: Manure and Water,” May 2016, David Osterberg, Nick Fetty and Nathan Wong

 

​Rushing to push Iowans off insurance​

Governor Reynolds and state legislators of both parties might want to consider how they would cope with the results of this legislation.

We have seen this film before. Legislators propose a new law that they claim will improve health care, but pushes millions off of health coverage, strips away protections in current law, tells cash-strapped states to pick up the tab, and gives big breaks to the wealthy who don’t need help.

Did you walk out of the theater the first two times? Will you stay for this one? More importantly, will our senators?

In the coming days we will get an analysis of the new Senate bill from the nonpartisan Congressional Budget Office (CBO). The analysis may come with little time in advance of a vote, as the Senate leadership is attempting to rush to a vote before the public, let alone Senate members, have a chance to fully evaluate it. (That is not new, either.)

We all need a sense of what to look for in the official analysis of the new proposal — not what Senator McConnell or Sunday morning-show spin-masters tell us the bill would do.

First, what is the comparison point? To understand the impact on Iowans, the comparison should be to current law, not just to previous proposals.

More than the minor changes it makes to the previous Senate bill, or how it differs from the House-passed bill, we need to know from the new official analysis how this bill differs from current law that has extended health coverage to tens of millions across the country, and some 200,000 in Iowa.

We know, for example, that about 150,000 Iowans are covered by only one piece of the Affordable Care Act (Obamacare), the Medicaid expansion, and that this number will be 177,000 in 2019 if the expansion is preserved.

However, the Medicaid expansion would effectively be eliminated under the new Senate plan, as in the previous, stalled Senate proposal and the House-passed bill. In none of these proposals do we see opportunities to further increase access to insurance for those who are most vulnerable.

In the end, isn’t that what we would expect health care reform to do? Provide more coverage, more efficiently, to all. Continual tweaks in the current and recent Washington plans don’t change a fundamental problem: Millions nationally, and hundreds of thousands in Iowa, would lose health insurance.

Put in stark terms: When people lose health insurance, they can lose access to health care. When that happens, they become sicker. Or they take on debt they can never overcome. Some die.

Ultimately, our state leaders in Iowa — the Governor, and state legislators of both parties — might want to consider how they would cope with the results of this legislation. Are they content with the U.S. Senate and House pushing more budget problems onto their desks, and to Iowa taxpayers? That is the choice Senators Grassley and Ernst will have in the coming days.

 

owen-2013-57Mike Owen is executive director of the nonpartisan Iowa Policy Project in Iowa City.

Contact: mikeowen@iowapolicyproject.org

Health exchanges: Why not fix?

Iowa’s insurance exchange has only one insurance company offering policies. But instead of fixing that, our representatives are using it as an excuse to repeal Obamacare, including the Medicaid expansion.

What would be your response if someone said to you: “The transmission in my car needs an overhaul. This just proves vehicular transportation doesn’t work, so I am going to get rid of my car and my pickup, even though the truck is still running fine.” You would probably think they were crazy. Why not just fix the car’s transmission?

Yet this is the logic being put forward by Senator Grassley and many others as they seek to repeal Obamacare. Yes, we have a problem with the insurance exchange in Iowa, where we now have just one insurance company offering policies. But instead of pursuing solutions to that problem, our representatives are using it as an excuse to repeal Obamacare, including the Medicaid expansion, which has nothing at all to do with the insurance exchange and in fact is still in good running order.

The lack of insurers in the Iowa exchange is largely a self-inflicted problem. Insurers have left the market in part because the state of Iowa did so little to encourage people to sign up, and to provide assistance in navigating the exchanges. Iowa was also extremely generous in allowing people to continue with existing poor-quality insurance.

The problem was worsened by President Trump’s efforts to sabotage the exchanges during the final weeks of the annual sign-up in January by banning all advertising and encouraging people to think Obamacare was going to end. As a result, the number enrolling in the exchanges, which had been on a pace to exceed that of the previous year, ending up falling short.[1] Too few younger and healthier people enrolled, leaving the insurance companies with older and sicker people.

There are solutions to this problem. Both the Iowa Insurance Commissioner and Iowa Democrats have proposed measures to solve the exchange problem at the state level. But the House and the Senate bills repealing and replacing Obamacare, instead of shoring up the exchanges, repeal the individual mandate. Analyses of their replacement provisions predict that they would worsen the problem instead of solving it, leaving the exchanges with even fewer healthy individuals.[2]

Now about the pickup truck. The Senate’s Better Care Reconciliation Act (BCRA) would likely result in 232,000 Iowans losing health insurance coverage over the next five years.[3] Three-fourths of them would become uninsured because of the loss of Medicaid, the rest because of cuts in premium assistance for policies purchased on the exchange.

Iowa expanded Medicaid eligibility (with 90 percent federal funding under Obamacare) to include low-income non-elderly adults, most of whom are working in low-wage jobs with little or nothing in benefits. The BCRA would effectively end the Medicaid expansion for about 177,000 Iowans.[4] This will hit rural Iowa the hardest, and it will undermine the finances of rural hospitals.

The Medicaid expansion has nothing to do with the health insurance exchanges. Our representatives should stop using a fixable problem with the exchanges as an excuse for passing a broad bill that ends health insurance for tens of thousands of Iowans.

[1] Center on Budget and Policy Priorities, Sabotage Watch: Tracking Efforts to Undermine the ACA. http://www.cbpp.org/sabotage-watch-tracking-efforts-to-undermine-the-aca

[2] Jacob Leibenluft and Aviva Aron-Dine. Senate Health Bill Can’t Be Fixed; Reported Changes Would Not Affect Bill’s Core Features. Center on Budget and Policy Priorities, July 10, 2017. http://www.cbpp.org/research/health/senate-health-bill-cant-be-fixed

[3] Linda Blumberg et al. State-by-State Coverage and Government Spending Implications of the Better Care Reconciliation Act. http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2017/rwjf438332

[4] Robert Wood Johnson Foundation and the Urban Institute. The Impact of Per Capita Caps on Federal and State Medicaid Spending. March 2017.

Peter Fisher, Research Director, Iowa Policy Project & Iowa Fiscal Partnership

pfisher@iowapolicyproject.org

Why not a special session?

Now is the time to be speaking frankly about the longer-term impacts of health care policy — and that might make a special session useful, sooner rather than later.

Long-term impacts could be decided in short order;
Might not our state lawmakers want to weigh in?

If anything has been clear about the current health-care debate in Washington, it is that little is clear — except the likelihood that (1) people will lose insurance coverage and thus access to health care, and (2) this will pose new challenges for state government.

That being the case, it seems a good time for the Legislature to return to Des Moines and sort it out, sooner rather than later. It will be easier for legislators to talk to their federal counterparts about all this before legislation passes than afterward.

Because of the Affordable Care Act (Obamacare), the Medicaid expansion serves about 150,000 Iowans, and would serve an estimated 177,000 Iowans in 2019 if preserved. But those Iowans — and some 55,000 more — would be in jeopardy of losing insurance under legislation pending in the Senate. If the enhanced federal share of funding for Medicaid expansion is reduced or eliminated under any legislation to come — and both the House and Senate bills currently would do this — states would have a choice: Fill in the gap or let people go uninsured.

Oh, and if you’re going to choose to fill in the gap, go ahead and plan now on what will have to be cut to compensate for it. K-12 education, perhaps? Even more cuts to the regents institutions? Child care? Water protection? Law enforcement and corrections?

Already, legislators and Governor Kim Reynolds are facing those kinds of questions amid a looming fiscal shortfall and speculation about a possible special session.

In The Des Moines Register this week, columnist Kathie Obradovich suggested Governor Reynolds “is prudent to wait until fall to make a decision on a special session but that doesn’t mean she should avoid talking about it. Now is the time to be speaking frankly with Iowans and individual legislators, identifying the causes and consulting on potential solutions.”

Now is also the time to be speaking frankly about the longer-term impacts of health care policy — and for that reason, waiting until fall might be too late. Legislative leaders and the Governor right now could be bringing in experts for a special session to discuss the potential impacts, and reach out to the congressional delegation, before decisions are made that restrict state budget choices for many years to come.
Unless, of course, they want to see budget crunches and special sessions more frequently.
Mike Owen, Executive Director of the Iowa Policy Project
mikeowen@iowapolicyproject.org

A look at future health care in Senate plan

Under the Senate health proposal, uninsurance in Iowa would be more than double what it would be under the current Affordable Care Act.

What Iowans need to know about coverage and costs

Health care policy is a complex issue. There’s no getting around that. But one way to consider the options vs. what we have is to look at basic, reliable estimates of the real-life impacts of the policy choices. How many Iowans would have insurance, and how many would not?

The Urban Institute has state-by-state estimates of these impacts. By 2022 — five years from now — under the Senate’s proposed Better Care Reconciliation Act, uninsurance in Iowa would more than double. Across the board of various population groups, significantly more Iowans (including children) would be uninsured than under the current Affordable Care Act, (ACA, or ObamaCare).

According to the Urban Institute:

• 148,000 non-elderly adults would be uninsured, or 8 percent, under the ACA, compared with 351,000 under BCRA, or 19 percent. This is an increase of 137 percent.

• 25,000 children would be uninsured, or 3.2 percent, under the ACA, compared with 54,000 under BCRA, or 6.9 percent. This is an increase of 117 percent.

• 115,000 non-elderly, non-Hispanic white Iowans would be uninsured under the ACA, or 5.4 percent, compared with 306,000 under BCRA, or 14.3 percent. This is an increase of 167 percent.

• 38,000 non-elderly Hispanic Iowans would be uninsured under the ACA, or 16.6 percent, compared with 53,000 under BCRA, or 23 percent. This is an increase of almost 39 percent.

For more about the impacts of the Senate proposal, see this Iowa Fiscal Partnership backgrounder by Peter Fisher of the Iowa Policy Project.

Senate Health Plan Hits Rural and Older Iowans Hardest

IOWA FISCAL PARTNERSHIP BACKGROUNDER

Plan would finance tax cuts for wealthy as 232,000 Iowans lose health coverage

PDF (2 pages)

By Peter Fisher, Iowa Policy Project

The overall effect is now clear for the Senate’s attempt to repeal and replace Obamacare — the Better Care Reconciliation Act (BCRA): It would cause millions to lose health insurance in order to finance tax cuts to the wealthiest Americans and corporations. The number of uninsured would soar in part because the BCRA cuts the subsidies that made health insurance affordable to millions of Americans, and in part because it would likely mean the end of the Medicaid expansion in Iowa and other states.[1] New estimates today show that 232,000 Iowans would lose health insurance coverage by 2022 under the BCRA. The percent of nonelderly Iowans who are uninsured would soar from 6.6 percent to 15.4 percent, reversing the gains achieved by the Affordable Care Act (ACA).[2] Nationally, 72 percent of those who would lose insurance coverage are in families with a full-time worker, as both the subsidies for purchase of insurance and the Medicaid expansion under the ACA provided insurance to low-wage workers whose jobs provided little in benefits.

The Senate bill would increase health insurance costs for many who now buy private insurance through the exchange or marketplace, and who receive subsidies in the form of tax credits under the ACA (Obamacare). It would do that by increasing premiums and reducing subsidies. Those premium increases would hit older Iowans especially hard, including those with incomes too high to qualify for subsidies, under either the ACA or the BCRA. That is because the ACA allows insurance companies to charge premiums based on age that vary only by 3 to1, while the BCRA increases that ratio to 5 to 1. Someone age 64, in other words, could be charged five times the premium charged a 21-year-old, instead of just three times. The result under the Senate bill would be lower premiums for the young, but substantially higher premiums for those who are older (but still under 65, where Medicare takes over.)

Basic RGB

The table above illustrates how the BCRA would increase health insurance costs for older Iowans, in urban counties and in rural counties. The table assumes that a 60-year-old Iowan purchases a Silver Plan, the lowest cost plan that qualifies for subsidies now under the ACA, in 2020. It compares the cost (the premium paid less the tax credit), first assuming the ACA is still in place, then assuming the BCRA has replaced it. The comparison takes into account both the increase in premiums due to the BCRA’s higher age ratio, and the reduced premium subsidies.

Statewide, the effect of the BCRA would be to increase the cost of a comparable insurance plan by $2,881 on average for a 60-year-old with an annual income of $20,000. The increase would range from $2,340 in the county with the lowest cost impact, to $4,640 in the highest cost county. For a 60-year-old with $40,000 income, the cost increase ranges from $3,630 to $5,940, with $4,177 the statewide average.

At $50,000 the impact of the BCRA more than doubles. That is because an individual with that income level still receives some subsidy under the ACA, but nothing under the Senate bill.[3] The net cost jumps up on average by about $10,100, and exceeds $14,000 in 17 counties. At $60,000 a year income, or any income higher than that, subsidies are not available under either the ACA or the BCRA. But premiums would have risen substantially under the BCRA because of the age ratio change. So any 60-year-old purchasing a policy in Iowa could expect to see costs rise by $3,000 to $5,000.

Because of the changing age ratio, some younger Iowans would see a net reduction in costs because of lower premiums. A 27-year-old Iowan with income over $30,000 would likely see a modest net savings of $250 to $350 per year on average, with that number rising to $850 in some cases. But if that person earned just $10.00 an hour, or the minimum wage, their net cost would increase by about $650 on average. Middle-aged Iowans (age 40) with modest incomes would also see an increase in net costs of insurance, even with an income of $30,000, of $400 to $900.[4]

The table also shows that the net increase in costs is higher in rural counties than in Iowa’s 21 counties that are part of a metropolitan area. This results from the higher cost of health care in rural Iowa.[5] This differential rural impact applies as well to the case of the 40-year-old, regardless of income, and to the 27-year-old with lower income.

The upshot: If you are between about 55 and 65, the BCRA would drive up your health insurance costs dramatically, regardless of your income. If you are a low-wage worker, especially if you live in a rural area with higher health insurance costs, you would also face higher net premiums to purchase insurance. Those higher costs will drive some to go uninsured, most likely the healthiest, which will once again threaten the viability of the insurance market.

[1] Iowa Policy Points blog, Iowa Policy Project, June 26, 2017. https://iowapolicypoints.org/2017/06/26/any-way-you-cut-it-americans-lose-health-coverage/

[2] Linda Blumberg et al. State-by-State Coverage and Government Spending Implications of the Better Care Reconciliation Act. http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2017/rwjf438332

[3] The ACA ends subsidies at 400 percent of the federal poverty level ($50,100 for an individual) whereas the BCRA ends subsidies at 350 percent of poverty or $43,875.

[4] The estimates in this paragraph are also based on population-weighted county figures from the Kaiser Foundation report cited below the table.

[5] The ACA bases subsidies on a silver plan, whereas the BCRA bases it on a bronze plan, which covers a substantially smaller share of health care costs (58 percent instead of 70 percent), generally through higher deductibles and co-pays. To make a fair comparison, we assumed the same quality Silver plan was purchased. The additional premium required to get a sliver instead of a bronze plan is entirely at the individual’s expense under the BCRA, and that expense is generally higher in rural areas.

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Peter Fisher is research director at the nonpartisan Iowa Policy Project (IPP). The Iowa Fiscal Partnership is a joint public policy analysis initiative of IPP in Iowa City and the Child & Family Policy Center in Des Moines. Find reports at http://www.iowafiscal.org.