Losing jobs and health access

As Iowa’s unemployment rate climbs towards numbers not seen since the Great Depression of the 1930s, we are shedding health coverage — in the midst of a sustained public health crisis — almost as fast as we are shedding jobs.

One of the cruelest ironies of the COVID-19 unemployment crisis is that, alongside the job losses, many workers and their families are also losing health coverage.

In Iowa, almost two-thirds (64 percent) of the nonelderly population rely on employment-based health insurance. As Iowa’s unemployment rate climbs towards numbers not seen since the Great Depression of the 1930s, we are shedding health coverage — in the midst of a sustained public health crisis — almost as fast as we are shedding jobs.

Even in good times, our crazy patchwork of health coverage — job-based care for most, Medicare for the elderly, Medicaid for low-income families, the ACA “marketplace” for others, and no coverage at all for the rest — is an engine of inequality. The better the job, as a rule, the better the health coverage. And in bad times, that coverage can easily disappear. Our reliance on job-based coverage, as one health policy expert famously put it, is like an umbrella that melts in the rain.

By one estimate (through May 14), about half of the 300,000 Iowans who lost their jobs in the COVID-19 recession also lost their health insurance. And this is a conservative estimate, as it does not count family members who might have relied on the same coverage and it is based only on those who lost their jobs and filed an unemployment claim.

These workers have some options — although the interruption of coverage alone is a frightening prospect in these troubled times. A lucky few might be able to pick up coverage through another family member who remains employed (and insured). Those losing job-based coverage have the “COBRA” option of continuing coverage by paying the full premiums themselves. But this is a costly option (the annual premium for job-based family coverage in Iowa is over $18,000) that few can afford.

Most displaced workers will turn to public programs. Iowa’s Medicaid program offers coverage to adults earning less than 138 percent of the federal poverty level ($16,791 for an individual, $28,888 for a family of three), and Medicaid and CHIP cover children in families with incomes up to 302 percent of the federal poverty level ($65,594 for a family of three). Unemployment benefits count towards this threshold, but the supplemental $600/week in Pandemic Unemployment Compensation (available through the end of July) does not.

Those whose family incomes fall above the Medicaid or CHIP thresholds have the last option of the Affordable Care Act “marketplace” insurance. Iowa’s health insurance exchange is a “federally facilitated” marketplace, which means it cannot allow open enrollment outside the conventional enrollment window in November.

But loss of a job (and job-based insurance) does qualify for off-cycle enrollment, and the premium assistance available for those purchasing at least a bronze plan on the exchange can substantially reduce costs for those with income under three to four times the poverty level. But here again there is a catch: Unemployment benefits count as income in determining both eligibility for ACA assistance and the amount of the assistance.

All this underscores the inequity and inefficiency of our job-based health care system. It is uneven and unreliable. And it fails at its most elemental goal: to protect working Iowans from risks that are beyond their control.

Colin Gordon is senior research consultant for the nonpartisan Iowa Policy Project (IPP) and a professor of history at the University of Iowa. He has led IPP’s State of Working Iowa analyses since 2001, and is author of Dead on Arrival: The Politics of Health Care in Twentieth Century America, and Citizen Brown: Race, Democracy, and Inequality in the St. Louis Suburbs.

Time for state to act

170118_capitol_170603-4x4The Pelosi-Mnuchin stimulus package that passed the U.S. House on Friday includes many measures to protect ordinary Americans who may see lost wages or who may need to stay away from work because someone in the family needs attention.

According to The Washington Post:

“The agreement reached Friday is primarily aimed at expanding the safety net to cope with the potentially catastrophic economic impact of the coronavirus. In addition to ensuring free coronavirus testing, the plan would dramatically increase several benefits, particularly family medical leave and paid sick leave, while also bolstering unemployment insurance; spending on health insurance for the poor; and food programs for children and the elderly.”[1]

The food program expansion “nullifies existing work requirements on the food stamp program.”[2] The medical leave and family leave section will allow up to two-thirds of salary to a great number of employees including full tax credits from employment tax for self-employed individuals.[3] The federal share of Medicaid is boosted and unemployment insurance is strengthened.

According to the Center on Budget and Policy Priorities (CBPP), the Medicaid boost means an additional $240 million is available for Iowa.[4] Noted CBPP’s Jennifer Sullivan:

The House COVID-19 bill’s temporary Medicaid funding boost, if in effect for all of calendar year 2020, would deliver roughly $35 billion in immediate, needed relief to states, which will face growing costs due to the virus and a likely economic downturn. … Similar measures have been a critical part of economic stimulus packages under both Democratic and Republican administrations….

The bill, expected to pass the Senate in a few days, addresses what many expect to be a downturn in the economy caused by the pandemic reaching U.S. shores.

Responsible actions at the federal level require a state response as well. Iowa Policy Project blog posts in recent days have noted good opportunities:

First, Iowa needs improvements in the unemployment system: (1) Relax the job search requirements to enable individuals forced into unemployment by the virus to collect UI benefits; (2) Allow individuals forced to take a leave of absence to collect UI during that period; (3) Establish procedures for individuals losing a job for health safety reasons or to care for a family member with the virus to qualify for UI, and (4) Establish rules under which employers’ unemployment experience rating is not harmed by virus-related layoffs.[5]

Second, Iowans need strong Medicaid and SNAP benefits now more than ever. The safety net helps us all — not just current beneficiaries, but also those on the edge of financial security and the general economy. Any legislation, such as SF430 and HF2030, that imposes new bureaucratic hurdles for struggling Iowans not only will take food and doctor’s visits away when people need them the most, but hurt local communities as well.[6]

[1] Erica WernerMike DeBonisPaul Kane and. Jeff Stein. The Washington Post, “House passes coronavirus economic relief package with Trump’s support,” March 14, 2020. https://www.washingtonpost.com/us-policy/2020/03/13/paid-leave-democrats-trump-deal-coronavirus/
[2] Ibid

[3] H. R. 6201 Making emergency supplemental appropriations for the fiscal year ending September 30, 2020, and for other purposes. Page 93 and 103. https://docs.house.gov/billsthisweek/20200309/BILLS-116hr6201-SUS.pdf

[4] Jennifer Sullivan, Center on Budget and Policy Priorities, “Medicaid Funding Boost for States Can’t Wait,” updated March 13, 2020. https://bit.ly/3d1jPBQ

[5] Peter Fisher. IowaPolicyPoints.org blog post,Protecting workers from coronavirus impacts.” March 14, 2020.

[6] Natalie Veldhouse. IowaPolicyPoints.org blog post, “Make Iowa resilient: Strengthen supports for working families.” March 13, 2020.

osterberg_david_095115David Osterberg co-founded the Iowa Policy Project and is a researcher with the organization.

dosterberg@iowapolicyproject.org

 

Make Iowa resilient: Strengthen supports for working families

170803-healthcare-acaThe Coronavirus (COVID-19) crisis is a good time to recognize the strong public structures we have in place to protect Iowans most vulnerable to economic challenges. Two federal-state programs are ready to address times like these: Medicaid and the Supplemental Nutrition Assistance Program, or SNAP.

A health emergency is an opportunity to bolster both programs to make sure they operate as intended, mitigating the impact on Iowans while our state and local leaders do what they can to contain the spread of the virus.

These two work support programs ensure that Iowans have access to food and medical care. The accessibility and adequate funding of these programs ensure all Iowans are protected. The specific programs help those who have fallen on hard times. Making sure everyone in society gets health care reduces the transmission of disease. When schools are closed, children who get free meals need SNAP to ensure there is enough food at home. These are especially important concerns during crises.

Ironically, the integrity of these programs has been threatened recently at the federal and state levels:

  • State and federal attempts to impose additional work reporting requirements and redundant quarterly eligibility checks for benefits would kick some families off of these vital work supports.
  • Federal rule changes including time limits on benefits and eliminating efficient and streamlined processes to qualify, as well as budget cuts, all threaten the ability of SNAP to prop up workers, families and communities during an economic slowdown that may be one of the impacts of COVID-19.
  • Similarly, budget cuts and the move to block grants fly in the face of Medicaid’s stated goal to provide health care to low-income Americans especially during an economic downturn.

We need Medicaid and SNAP now more than ever. It would be a timely move for lawmakers to step back and recognize that the safety net helps us all. Iowa bills SF430 and HF2030 impose bureaucratic hurdles that will serve to take food and doctor’s visits away from Iowans.

Especially during a public health crisis, we need our leaders looking for ways to help all Iowans get ahead.

2018-NV-6w_3497(1)Natalie Veldhouse is a research associate at the nonpartisan Iowa Policy Project. nveldhouse@iowapolicyproject.org

Work supports put Iowans ahead

Legislators are proposing costly, punitive rules for food and medical care that will fail to encourage work or boost health and financial security for low-income families.

Multiple bills moving through the Iowa Legislature attempt to take food and medical care away from Iowans. SF430 and HF2030 seek to impose harsh work requirements and a redundant eligibility verification system. Both of these costly proposals would needlessly expand bureaucracy while failing to enable work, financial security or health for Iowans.

Instead of promoting better circumstances for workers, work requirements do the opposite. They push families off of vital programs such as Medicaid and the Supplemental Nutrition Assistance Program (SNAP) — even though access to adequate medical care and food is important for finding and maintaining employment.

Analysis by the Legislature’s nonpartisan fiscal staff in 2019 estimated that imposing parental work requirements on SNAP participants would add $2.5 million in administrative costs in the year implemented, followed by an ongoing annual cost of half a million dollars per year.[1]

Pushing an additional eligibility verification system would have cost $25 million per year after an initial $16 million in FY2020 to hire more than 520 state employees to verify eligibility for Iowans on work support programs including Medicaid and SNAP, according to another 2019 Legislative Services Agency fiscal note.[2] 

The sole result of such bills, if enacted, will be to get Iowans off of work-support programs — not to encourage work. IPP’s latest “Cost of Living in Iowa” analysis found that work-support programs such as SNAP and Medicaid are instrumental in helping Iowa working families bridge the gap between take-home earnings and basic needs. With 1 in 5 Iowa working households unable to meet basic needs on income alone, promoting access to work supports is important.[3]

Policies that enable work and economic prosperity include raising the minimum wage, expanding eligibility for Child Care Assistance, expanding family leave, and investing in job skills training. SF430 and HF2030 would penalize Iowans that are having difficulty making ends meet, in an economy with many low-wage jobs and inadequate benefits.

Remember, taking away food, prescriptions and doctor’s visits from Iowans in no way promotes work.

[1] Jess Benson, “SF 430 – Supplemental Nutrition Assistance Program (SNAP), Parent Work Requirements” March 2019. Legislative Services Agency. https://www.legis.iowa.gov/docs/publications/FN/1039301.pdf

[2] Jess Benson, “Fiscal Note: SF 334 – Medicaid, Supplemental Nutrition Assistance Program (SNAP) Eligibility Verification.” February 2019. Iowa Legislative Services Agency. https://www.legis.iowa.gov/docs/publications/FN/1038439.pdf

[3] Peter Fisher and Natalie Veldhouse, “Strengthening Pathways to the Middle Class: The Role of Work Supports. The Cost of Living in Iowa 2019 Edition, Supplement.” January 2020. Iowa Policy Project. http://iowapolicyproject.org/2020docs/200108-COL2.pdf

2018-NV-6w_3497(1)Natalie Veldhouse is a research associate at the nonpartisan Iowa Policy Project.

nveldhouse@iowapolicyproject.org

 

 

New obstacles for Iowa families

Millions for work support oversight that would likely result in no savings

Senate File 334 could take food off the table and restrict health care access for some Iowans, while taking money away from much needed programs. The bill would spend $25 million per year after an initial $16 million in FY2020 to hire more than 520 state employees to verify eligibility for Iowans on work support programs such as Medicaid and SNAP (food assistance).[1] This legislation is brought to you by a Koch-funded lobbying group out of Florida.

Iowa’s Legislative Service Agency analysis indicates that the bill’s proposed “quarterly reviews have the potential to reduce public assistance enrollment, but no significant savings are expected because many items that would be reviewed quarterly are currently checked on a frequent basis.”[2]

SNAP helped more than 330,000 Iowans in January of 2019.[3] More than 560,000 Iowans are covered by Medicaid.[4] Many Iowans receiving help from these work support programs are children; many more are elderly persons in nursing homes.

Make no mistake — this bill has the sole intention of getting Iowans off of work support programs.

One in six Iowans living in working households is unable to afford basic needs such as groceries and health care on income alone.[5] Low wages are the problem and spending millions in taxpayer money to duplicate work support verification will do little to help Iowans get ahead.

SNAP is important for child development, educational outcomes and lifetime earnings.[6] Half of Medicaid enrollees in Iowa are children,[7] and 44 percent of Medicaid spending goes to services for older Iowans.[8] The challenge to Iowa policy makers is how to make sure people who need these supports can get them, not to put new obstacles in their way.

Policies that would really help Iowans get ahead should concentrate on raising wages to account for rising worker productivity. Helpful policies should reinstate workers’ rights and protections. Other policy solutions include expanding Iowa’s Earned Income Tax Credit and Child Care Assistance. It is to these solutions where Iowans need to turn their attention.

 

[1] Jess Benson, “Fiscal Note: SF 334 – Medicaid, Supplemental Nutrition Assistance Program (SNAP) Eligibility Verification.” February 2019. Iowa Legislative Services Agency. https://www.legis.iowa.gov/docs/publications/FN/1038439.pdf

[2] Ibid.

[3] Iowa Department of Human Services, “Food Assistance Report Series F-1.” January 2019. http://publications.iowa.gov/29783/1/FA-F1-2016%202019-01.pdf

[4] American Community Survey, “Health Insurance Coverage Status and Type of Coverage by State and Age for All People: 2017. September 2018. U.S. Census Bureau. https://www.census.gov/data/tables/time-series/demo/health-insurance/acs-hi.html

[5] Peter Fisher and Natalie Veldhouse, “The Cost of Living in Iowa – 2018 Edition: Many Iowa Households Struggle to Meet Basic Needs.” July 2018. Iowa Policy Project. http://iowapolicyproject.org/2018docs/180702-COL2018-Part2.pdf

[6] Feeding America, “Child Food Insecurity: The Economic Impact on our Nation.” 2009. https://www.nokidhungry.org/sites/default/files/child-economy-study.pdf

[7] American Community Survey, “Health Insurance Coverage Status and type of Coverage by State and Age for All People: 2017.” Table H105. September 2018. U.S. Census Bureau. https://www.census.gov/data/tables/time-series/demo/income-poverty/cps-hi.html

[8] Steve Eiken, Kate Sredl, Brian Burwell & Angie Amos, “Medicaid Expenditures for Long-Term Services and Supports in FY 2016.” Table 31. Iowa LTSS Percentage Trends. https://www.medicaid.gov/medicaid/ltss/downloads/reports-and-evaluations/ltssexpenditures2016.pdf

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Natalie Veldhouse is a research associate for the nonpartisan Iowa Policy Project. nveldhouse@iowapolicyproject.org

Drug testing: Needless, costly, burdensome

To assure access to health care, drug testing just gets in the way

Multiple bills introduced in the 2019 Iowa legislative session would limit access to health care by posing bureaucratic hurdles to working families needing help.

Drug-testing Medicaid recipients is one of those ideas. Already shown to be costly and ineffective in other states, the idea is one more solution in search of a problem. Studies show that drug use among work support recipients is lower than the general population.[1] In most states, less than 1 percent of applicants have tested positive.[2]

Neighboring Missouri provides a lesson for Iowa on cost. Missouri spent $336,297 on drug testing of Temporary Assistance for Needy Families (TANF) in 2017.[3] After initial screening, the state tested 108 of 32,774 TANF applicants, finding 11 positive results. That’s an investment of over $30,000 per positive test. Another 305 applicants did not show up for a drug test or refused to take one.[4]

Iowa is familiar with these costs. Last session, a similar bill was proposed to implement drug testing for SNAP and Medicaid recipients. A Department of Human Services administrator estimated that costs to the state would have been at least $100 million.[5]

Medicaid plays a vital role in insuring more than 260,000 Iowa children.[6] Restricting access to medical care through drug testing poses a threat to child well being, by reducing resources available to the household as a whole.[7]

Over 225,000 Iowans living in working households struggle to make ends meet.[8] Medicaid and Affordable Care Act subsidies are important work supports that help families get by when wages aren’t enough to cover basic costs.

In Iowa, the large majority of Medicaid recipients who can work do work. Eighty-seven percent live in a working family and 72 percent work themselves.[9]

Instead of making it more difficult for low-income families to get the medical care they need, Iowa can invest in its workers by expanding the state Earned Income Tax Credit and Child Care Assistance programs. Other alternatives include raising wages to more accurately reflect workers’ productivity and higher living costs, or adequately funding mental health care.

 

[1] Center on Law and Social Policy, “Drug Testing SNAP Applicants is Ineffective and Perpetuates Stereotypes.” July 2017. https://www.clasp.org/sites/default/files/publications/2017/08/Drug-testing-SNAP-Applicants-is-Ineffective-Perpetuates-Stereotypes.pdf

[2] Center on Law and Social Policy, “Drug Testing and Public Assistance.” February 2019. https://www.clasp.org/publications/fact-sheet/drug-testing-and-public-assistance

[3] Ibid.

[4] Amanda Michelle Gomez and Josh Israel, “States waste hundreds of thousands on drug testing for welfare, but have little to show for it.” May 2018. Think Progress. https://thinkprogress.org/states-waste-hundreds-of-thousands-on-drug-testing-for-welfare-3d17c154cbe8/

[5] O. Kay Henderson, Iowa Senate bill to require drug tests, work for welfare.” February 2018. Radio Iowa. https://www.radioiowa.com/2018/02/15/iowa-senate-bill-to-require-drug-tests-work-for-welfare/

[6] American Community Survey, “Health Insurance Coverage Status and Type of Coverage by State and Age for All People: 2017. September 2018. U.S. Census Bureau. https://www.census.gov/data/tables/time-series/demo/health-insurance/acs-hi.html

[7] Center on Law and Social Policy, “Drug Testing and Public Assistance.”

[8] Peter Fisher and Natalie Veldhouse, “The Cost of Living in Iowa 2018 Edition Part 2: Many Iowa Households Struggle to Meet Basic Needs.” July 2018. Iowa Policy Project. http://iowapolicyproject.org/2018Research/180702-COL-Part2.html

[9] Rachel Garfield, Robin Rudowitz, & Anthony Damico, “Understanding the Intersection of Medicaid and Work.” January 2018. Kaiser Family Foundation. https://www.kff.org/medicaid/issue-brief/understanding-the-intersection-of-medicaid-and-work/

 

2018-NV-6w_3497(1)

 

Natalie Veldhouse is a research associate for the nonpartisan Iowa Policy Project. nveldhouse@iowapolicyproject.org

Boost work: Keep Medicaid accessible

Complicating Iowans’ ability to get checkups and the medications they need will not improve workforce participation.

Iowa’s Medicaid program carries two major purposes. First, Medicaid provides medical care for the elderly; in fact, 44 percent of Medicaid spending goes for long-term services and supports for seniors.[1] About half of Iowa nursing home residents benefit from Medicaid.[2]

Second, Medicaid covers thousands of Iowans working in low-wage jobs with no health insurance benefits and to thousands of others who have a disability that prevents them from working. Nearly half of all Medicaid recipients in Iowa are children.[3]

The data show that Medicaid is an important work support. Most non-elderly adult Medicaid enrollees in Iowa work — 72 percent — and 87 percent live in a working family.[4]

Among Medicaid enrollees in Iowa, larger shares of African-American and Latino enrollees are working than whites. One-third of Iowa working Medicaid enrollees work in smaller companies, which likely do not provide employer-sponsored insurance. It might surprise Iowans to know the largest group of Iowa workers receiving Medicaid work in elementary and secondary schools.[5]

Imposing new requirements for Medicaid would complicate health-care access for low-wage workers, children, veterans, older Iowans and Iowans with disabilities. It would not improve workforce participation.

Contrary to some political claims, studies in case after case show the main impact of extra Medicaid requirements is not better jobs,[6] but disenrollment in Medicaid, worse health outcomes, less access to care, and financial insecurity.[7] Rather than promoting good health that is important for employment and productivity, added Medicaid eligibility requirements undermine the goal of encouraging work.

If policy makers’ goal is to increase workforce participation, more practical approaches exist in expanding the state Earned Income Tax Credit and Child Care Assistance eligibility.

Not only do new Medicaid requirements fail to encourage work, but they make sustaining coverage difficult for people who are exempt from work, such as Iowans with disabilities, who may face obstacles in documentation and verification. Workers with variable hours, particularly in food service, retail, and seasonal jobs, could face similar issues.

Many working Medicaid enrollees work full time, but their low annual wages still quality them for Medicaid.[8] Rural communities rely heavily on Medicaid; disenrollment could harm rural hospitals and restrict access to care for children, the elderly, and veterans.[9]

It makes no sense to restrict access to health care for Iowans who are working or are exempt due to age or disability status.

 

[1] Steve Eiken, Kate Sredl, Brian Burwell & Angie Amos, “Medicaid Expenditures for Long-Term Services and Supports in FY 2016.” Table 31. Iowa LTSS Percentage Trends. https://www.medicaid.gov/medicaid/ltss/downloads/reports-and-evaluations/ltssexpenditures2016.pdf

[2] Kaiser Family Foundation, “Medicaid’s Role in Nursing Home Care.” Table 1: Medicaid’s Role in Nursing Home Care, by State.  June 2017. https://www.kff.org/infographic/medicaids-role-in-nursing-home-care/

[3] American Community Survey, “Health Insurance Coverage Status and type of Coverage by State and Age for All People: 2017.” Table H105. September 2018. U.S. Census Bureau. https://www.census.gov/data/tables/time-series/demo/income-poverty/cps-hi.html

[4] Rachel Garfield, Robin Rudowitz, & Anthony Damico, “Understanding the Intersection of Medicaid and Work.” January 2018. Kaiser Family Foundation. https://www.kff.org/medicaid/issue-brief/understanding-the-intersection-of-medicaid-and-work/

[5] Ibid.

[6] LaDonna Pavetti, “Work Requirements Don’t Cut Poverty, Evidence Shows.” June 2016. Center on Budget and Policy Priorities.  https://www.cbpp.org/research/poverty-and-inequality/work-requirements-dont-cut-poverty-evidence-shows

[7] Hannah Katch, “Medicaid Work Requirements Will Harm Families, Including Workers.” February 2018. Center on Budget and Policy Priorities. https://www.cbpp.org/research/health/medicaid-work-requirements-will-harm-families-including-workers

[8] Ibid.

[9] Center on Budget and Policy Priorities, “How Medicaid Work Requirements Will Harm Rural Residents – And Communities.” August 2018. https://www.cbpp.org/research/health/how-medicaid-work-requirements-will-harm-rural-residents-and-communities

 

Natalie Veldhouse is a research associate for the nonpartisan Iowa Policy Project. nveldhouse@iowapolicyproject.org

For starters, issues to watch in 2019

There are many issues to watch in the new Iowa legislative session. Here is a non-exhaustive list, identifying where policy changes could affect opportunity for many thousands of Iowans.

With the 2019 session of the Iowa Legislature officially underway, the Iowa Policy Project is a dependable source for quality information and analysis on Iowa’s most pressing policy challenges. IPP’s Roadmap for Opportunity project will highlight and clarify many of these challenges as they emerge. Among issues to watch:

Public funds for private schools

Vouchers or “education savings grants” stand to take more money away from public schools and add to the $66 million Iowa taxpayers pay every year to support private education. Funding for Iowa’s public schools has failed to keep up with rising costs. Underfunded schools impact student development and workforce potential. Read more in our Roadmap piece, “Strengthening public education, no new subsidies to private schools” and the accompanying backgrounder, “Taxpayer support of private education in Iowa.”

Unemployment compensation

Unemployment insurance is an important program that supports workers experiencing temporary unemployment and acts as a macroeconomic stabilizer during economic downturn.[1] Because states are granted flexibility in shaping the program, there lies potential to undermine it, as other states have recently. More to come on this issue.

Attacks on public pensions

Maintaining a strong public pension system in Iowa ensures that we are able to attract and retain quality state employees who teach our children and protect our communities. It is important that Iowa wards off attempts to restructure the Iowa Public Employees’ Retirement System (IPERS) in ways that erode retirement security. For more, read our Roadmap piece, “IPERS works to boost retirees, economy.”

Further tax cuts

During the 2018 session, legislators passed a package of tax changes that largely benefit wealthy Iowans, with 2.5 percent of Iowa earners taking nearly half of tax cuts. The current administration has signaled support for further cuts that would endanger services that promote thriving communities such as education and healthcare. Read more on “What real Iowa tax reform would look like.”

Protecting Iowans’ health

Iowa’s privatized Medicaid system continues to cut off patient care and miss payments to providers. With little hope of returning the program to state control anytime soon, we must ensure that cost savings are achieved by increasing innovation and efficiency, not by undercutting health care providers or denying services to the sick and disabled. We should also stay away from Medicaid work requirements, which lead to disenrollment and additional barriers for elderly and disabled Iowans without meaningfully improving employment.[2] For more, read out Roadmap piece, “Restoring success of Iowa Medicaid.”

As noted above, this is not an exhaustive list — only a start. Stay up to date on our analysis through Facebook, Twitter, and our email newsletter.

[1] Chad Stone and William Chen, “Introduction to Unemployment Insurance.” July 2014. Center on Budget and Policy Priorities. https://www.cbpp.org/sites/default/files/atoms/files/12-19-02ui.pdf

[2] Center for Law and Social Policy, “Medicaid Works: No Work Requirement Necessary.” December 2018. https://www.clasp.org/publications/report/brief/medicaid-works-no-work-requirement-necessary

Natalie Veldhouse is a research associate for the nonpartisan Iowa Policy Project. nveldhouse@iowapolicyproject.org

Focus on fixing insurance exchange

The problems with the insurance exchange in Iowa are fixable — and not a good excuse to fund tax cuts to the wealthy by forcing tens of thousands of Iowans off health insurance.

It’s time for Iowa’s congressmen and senators to start working on immediate measures to strengthen the health care system, and specifically the health insurance exchange, or marketplace. The obsession of some with bills to repeal and replace Obamacare has been a distraction from that task.

In recent days, bipartisan groups have sprung up in both the House and the Senate to begin developing legislation to stabilize the insurance market. These groups recognize the immediate need for measures to ensure that federal payments continue for cost-sharing reductions (CSRs) that help low-income people afford their copays and deductibles. Without the assurance that these payments will continue, premiums will rise sharply.

The president has threatened to continue his efforts to sabotage the Affordable Care Act (ACA) by ordering an end to CSRs. This threat has already prompted Medica, the only Iowa health insurance company still offering plans on the exchange, to plan for another premium increase.

The bipartisan efforts to shore up the insurance exchanges could include another important measure: a reinsurance program that would reduce the risk that a small number of high-cost customers will cause insurance company losses. The “million-dollar customer” has been cited as a factor contributing to the decisions of Wellmark and Aetna to exit the Iowa exchange. Reinsurance would establish a national pool to cover high-risk cases; this would allow companies to remain in the exchanges without drastic premium increases on everyone to pay for those few cases.

The Senate’s attempts to repeal and replace failed because they were wildly unpopular. These measures would have resulted in over 200,000 Iowans losing health insurance; would have effectively ended the expansion of Medicaid that covers thousands of low-wage workers; would have reduced Medicaid benefits for thousands of seniors, children, and people with disabilities; would have raised premiums and deductibles; would have gutted protections for persons with pre-existing conditions; and would have provided billions in tax cuts to wealthy individuals and corporations.

Another attack on coverage: Graham-Cassidy

Pragmatic efforts to stabilize the health insurance market stand in stark contrast to a last-ditch attempt to repeal and replace Obamacare that surfaced this week: the Graham-Cassidy plan. Like the previous failed bills, this plan would end the Medicaid expansion that now covers 150,000 Iowans.

Unlike previous repeal and replace bills, the Graham-Cassidy plan would also end the premium assistance that makes health insurance affordable to tens of thousands of low and moderate income Iowa families. While it replaces ACA funding of premium assistance and Medicaid expansion with a block grant, it provides no guarantee that the states will use that block grant to make health insurance affordable to those who need help the most. And the bill would further destabilize the insurance market by ending the mandate to purchase insurance, while making it more expensive, leaving insurance companies with the sickest and costliest customers.

The problems with the insurance exchange in Iowa are fixable. Let’s see if our Senators and Representatives actually try to fix those problems instead of using them as an excuse to fund tax cuts to the wealthy by forcing tens of thousands of Iowans off their health insurance.

Peter Fisher is research director of the Iowa Policy Project.

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