Unfunded Mandates? Not Quite, Governor

What is clear is that the mandates in the Affordable Care Act are not “unfunded.” Though Iowa will be required to cover a small portion of the costs of the Medicaid expansion, this hardly qualifies as “shackl[ing] Iowa taxpayers.”

Andrew Cannon photo
Andrew Cannon

This week, Governor Branstad signed Iowa on to a multistate lawsuit challenging health care reform. In his statement announcing that Iowa would join the suit, Governor Branstad said the health reform law would “shackle Iowa taxpayers for billions in unfunded mandates.”

You may be wondering what “unfunded mandates” he’s referring to. So am I.

He might be talking about the individual responsibility requirement, since that is the provision that is being challenged in the lawsuit. Section 1501 of the Affordable Care Act requires all individuals to maintain health insurance coverage or face a tax penalty (with exemptions for those with religious oppositions or with financial difficulties).

But the individual mandate is not “unfunded;” indeed, it is largely funded by the federal government. Individuals and families earning up to 400 percent of the federal poverty level  ($88,200 for a family of four) are eligible for premium assistance. The vast majority of Iowa’s uninsured, approaching 300,000 Iowans, will be covered by the Affordable Care Act’s expansion of Medicaid. After the Medicaid expansion, the majority of the remaining Iowans will be eligible for the health insurance premium tax credits. Only about 27,400 Iowans earned more than 400 percent of the FPL ($88,200 for a family of four) and were uninsured, on average, from 2008 to 2010.

On the other hand, Governor Branstad could have been referring to the expansion of Medicaid as an “unfunded mandate.” As noted above, the Affordable Care Act vastly expands the Medicaid program, allowing all individuals with income below 133 percent of FPL ($29,326 for a family of four) to enroll. Medicaid is jointly financed by the states and the federal government, with the feds picking up the lion’s share of the tab. In normal times, the federal government pays for around 63 percent of the Medicaid program in Iowa; in recent years, that has been increased to around 71 percent, thanks to the federal Recovery Act.

But unlike traditional Medicaid, which comprises a large portion of the state’s budget, the Medicaid expansion will be almost entirely funded by the federal government. In other words, no unfunded mandate here, either. During the first three years, (2014-2016) the costs of expansion will be fully covered by the federal government. In subsequent years, the federal government’s share of the expansion costs will decrease, but not by much. In 2020 and beyond, Iowa will only be paying for 10 percent of the cost of the Medicaid expansion.

The fate of the lawsuit (and thus reform) is unclear, at this point, though experts and administration officials alike are confident that health reform will survive the legal challenges. Given the diverse rulings to date, the challenge will likely be resolved by the Supreme Court.

What is clear, however, is that the mandates in the Affordable Care Act are not “unfunded.” Though Iowa will be required to cover a small portion of the costs of the Medicaid expansion, this hardly qualifies as “shackl[ing] Iowa taxpayers.”

Posted by Andrew Cannon, Research Associate

Reform should halt large rate increases

Health reform — the Affordable Care Act — attempts to make the market more affordable for individuals by allowing them to pool their risk together in a regulated marketplace called an exchange.

Andrew Cannon, research associate
Andrew Cannon

If Blue Shield of California gets its way, some of its individual market customers will see rate hikes as high as 59 percent.

You read that right: 59 percent. At the same time, we learned that health expenditures increased by their lowest rate in 2009.

So what gives?

We won’t know for sure until the state performs an actuarial review of the company’s request, but it seems that the problem in California is the same problem faced by customers of Anthem Blue Cross of California and Iowa’s Wellmark last year: The individual market doesn’t work.

Unlike employer-provided plans, which are purchased on the group market, the risk of medical cost in plans sold on the individual market is borne completely by the individual. Within a workplace, the risk that someone will fall ill is countered by the likelihood that other enrollees in the plan will stay healthy. Similarly, plans on the individual market are often subject to aggressive medical underwriting — or calculation of future medical costs based on medical history; plans in the group market are usually underwritten only on the age and sex of plan enrollees.

Health reform — the Affordable Care Act (ACA) — attempts to make this market more affordable for individuals by allowing individuals to pool their risk together in a regulated marketplace called an exchange. In addition to allowing individuals to pool their risk with other individuals, starting in 2014, the exchange will also tightly regulate how insurers deal with their customers.

Under the ACA, insurers will no longer be able to exclude pre-existing conditions, deny coverage, or base their premiums on anything other than age, sex, region the customer lives in, and smoking status. Further, individuals with income up to 400 percent of the federal poverty level ($88,200 for a family of four) will be eligible for assistance with their insurance premiums, on a sliding scale.

Though those affected by Blue Shield’s outrageous rate increase request won’t benefit from these reforms in the short term, the rate increase request illustrates the need for a robust exchange that provides attractive insurance options for individuals and small businesses and also provides a workable market for insurers to operate in.

Posted by Andrew Cannon, Research Associate

Implementing Health Reform: Early Successeses

A number of health-reform provisions already have taken effect, and are showing results.

Andrew Cannon, research associate
Andrew Cannon

The new health reform law is already helping thousands of Iowans and small businesses.

Though the major provisions of the health reform law won’t be implemented until 2014, a number of provisions have already gone into effect.

The new law provides tax credits to small businesses that offer health insurance to their employees. The rapid growth of premiums over the past decade have made insurance provision extremely difficult for small businesses. According to the Agency for Healthcare Quality and Research’s Medical Expenditure Survey, In Iowa, just 28 percent of firms with 10 or fewer offered insurance to employees, compared to 92 percent of firms with 100 or more employees.

The Wall Street Journal‘s Janet Adamy reported Tuesday that the percentage of small businesses with three to nine employees offering health insurance to employees has increased significantly over the past year — from 46 percent to 59 percent. Researchers at Bernstein Research attribute that growth to the health reform law’s small business tax credits.

In addition to small businesses, health reform is helping Iowa prepare for full implementation of the law and helping Iowa’s seniors. The state received a $1 million grant to plan for a Health Insurance Exchange, one of the key components of the overhaul.

Though Medicare recipients gained prescription drug coverage through Medicare Part D in 2003, the law had a $2,000 gap in coverage — often called the “donut hole.” Early implementation of health reform lessens that gap, by providing a $250 tax-free rebate to Medicare recipients. In Iowa, 17,774 Medicare beneficiaries have received the rebate.

Posted by Andrew Cannon, Research Associate

Why is Iowa government smaller?

Iowans might be surprised to learn that sensible measures indicate Iowa government actually has declined.

Andrew Cannon, research associate
Andrew Cannon

Calls for smaller government carry a number of distortions. Our roads, schools and public health, to name just a few publicly financed services, often operate with the bare minimum financing as it is.

The primary distortion, however, involves concepts about the size of our state government.

Iowans might be surprised to learn that sensible measures indicate Iowa government actually has declined.

Iowa’s General Fund spending as a share of the economy has decreased by more than 26 percent since the early 1990s.

When measured by personal income — all the income generated each year by all Iowans — General Fund spending peaked in Fiscal Year 1997, at 6.4 percent. In FY10, General Fund spending was just 4.7 percent of Iowans’ personal income.

And that is not just a result of the recent Great Recession and the 10 percent across-the-board budget cut by Governor Culver. In FY09, spending as a share of personal income was 5.5 percent — nearly a full percentage point lower than the high-water mark of the late 1990s.

Posted by Andrew Cannon, Research Associate

Figure 1 from IFP brief, "Getting Public Value Out of Our Public Dollars"
Figure 1 from IFP brief, "Getting Public Value Out of Our Public Dollars"