LITTLE ROCK — Requiring small co-payments of up to 250,000 new Medicaid enrollees for certain services is a potential carrot being considered by the administration of Gov. Mike Beebe to get enough votes to pass a federally supported expansion of Arkansas’ $4.6 billion Medicaid program.
Medicaid expansion promises to be a big issue when the Legislature convenes in January. Although formal discussions between Democrats and Republicans on the issue have yet to begin, behind-the-scenes strategy is already being crafted.
Many states are considering similar negotiating tactics, say Medicaid officials and experts, as they wrestle with whether to participate in the federally funded expansion of Medicaid authorized by President Barack Obama’s health-care law.
“We’re in the early explorative phase,” said Dr. Joe Thompson, state surgeon general. “But there is a clear recognition that patient engagement - or ‘skin in the game’ - is part of the future.”
Most current Medicaid recipients, about 780,000, don’t pay co-payments or deductibles. Certain programs, such as ARKids First Part B, have small co-payment amounts for certain services.
New co-payments or fees for people covered by the expansion would be designed to discourage things such as unnecessary emergency room visits while encouraging preventive services such as screenings.
Any change to Medicaid must be approved by the federal government. Earlier this year, the federal oversight agency Centers for Medicare and Medicaid Services gave a green light for the state to pursue an overhaul of its Medicaid payment structure. A similar OK would have to be reached with the agency for any type of Medicaid co-payments.
Thompson said federal approval of Medicaid co-payments could come through a waiver or as part of a legislative approval of Medicaid expansion, an option created by the Patient Protection and Affordable Care Act.
“We’re very open to talking about that because we do want to get to yes [on expansion],” said John Selig, director of the Arkansas Department of Human Services.
Arkansas Republicans have been mostly opposed to Medicaid expansion, which would be paid in full by the federal government until 2017. By 2020, the state’s share of the costs would rise to 10 percent.
Sen. Michael Lamoureux, R-Russellville, said his party wouldn’t agree to any expansion unless Democrats accept his party’s Medicaid proposals, including increased monitoring of fraud and abuse, random drug-testing for working-age adults and more eligibility verification for recipients.
Requiring some co-payments for Medicaid recipients was one of the suggestions by Republican leaders in a July letter to Beebe, Selig and state Medicaid Director Andy Allison.
“We’ve proposed co-pays for a long time. I’m glad to see that they’re warming up to the idea,” Lamoureux said.
The governor hasn’t had any specific conversations with lawmakers about Medicaid co-payments, but it’s an issue that “could be talked about,” said Matt DeCample, Beebe’s spokesman.
Beebe supports expansion, saying it would be good for the state’s economy and the right thing to do for Arkansas’ working poor.
But adding co-payments as a component of Medicaid expansion would be complex, DeCample said.
“That would end up being two discussions: one in the Legislature, and one between Arkansas and the federal government. It’s a complicated discussion,” DeCample said.
Selig said Medicaid co-payments are all on the table for January’s session. So are other measures to lower Medicaid costs through encouraging more responsibility from patients: more home visits by doctors’ staffs, paying doctors to more closely monitor their patients, even sending text message reminders for appointments and medication.
But the idea of requiring greater Medicaid patient accountability isn’t being touted just to sway Republican lawmakers, said Allison.
During discussions about the state’s Medicaid cost restructuring, providers have “universally” asked for measures to increase patient compliance and discourage unnecessary costs, he said.
“I would hate to see the issue characterized solely as negotiating over expansion. That’s not our sole interest,” Allison said.
The idea already has broad support among doctors, lawmakers from both parties and the general public.
“That is proof to me that this issue is not primarily partisan. And there clearly is room for common interest, common ground. I do think we’ll be looking to find that common ground,” Allison said.
The state hasn’t formally asked the federal government for permission to pursue co-payments, Selig said.
The former head of Centers for Medicare and Medicaid Services, the federal oversight agency, spoke at Arkansas Children’s Hospital in Little Rock on Thursday. Before his speech, Dr. Donald M. Berwick - who left the agency in December when his recess appointment ended - said he had reservations about requiring poor people to spend their own money on health care.
“The patient has all their skin in the game. They’re already there,” Berwick said. “My own view is that I’m very nervous about cost-shifting to Medicaid recipients on the whole. If co-payments are tried, they should be done very, very carefully.”
But Berwick strongly recommended that the state expand its Medicaid rolls.“Tweaks” could come later.
“I’m not sure it would be smart to walk away from that opportunity,” he said.
The upside of financial contributions from Medicaid recipients - however small and limited in scope - have obvious political upsides,Thompson said.
“The belief, strongly held on both sides of the aisle, is anything that is absolutely free may not be valued as much as something that you have some participation in,” Thompson said.
Much will depend in Little Rock and in Washington, D.C., on Tuesday’s election because any Medicaid expansion is part of Obama’s new health-care law. The GOP has vowed to overturn the law if it captures enough votes in Congress and wins the presidency.
The election will also determine whether the state GOP realizes enough political gains to capture a legislative majority.
Three Democratic lawmakers who were asked to comment on Medicaid expansion either didn’t return phone calls or declined to comment.
At the state level, Lamoureux predicts, Republicans -not Democrats - will be calling the shots on Medicare.
“I think they might have it backwards. We’ll have a list of reforms that we want to do. The [Republican] members guiding that policy might have a carrot to offer,” he said.
A “small amount” of expansion might be do-able if “all our reforms are implemented,” said Lamoureux, referring to the July letter. “But it wouldn’t be 250,000. If they’re not interested in compromise, then we’re not either. They’re not going to be telling us what the expansion is going to be.”
Front Section, Pages 1 on 11/05/2012