LITTLE ROCK — E-mails between Arkansas policymakers and leading Republicans show an effort to develop pro-expansion “talking points” to help sell an unprecedented Medicaid expansion deal to legislators.
State health-care policymakers and advisers also discussed how to mesh the expansion with the state’s existing payment overhaul for Medicaid, the e-mails show.
The e-mails flowed between GOP leaders and administration officials in the days after Gov. Mike Beebe’s announcement that U.S. Secretary of Health and Human Services Kathleen Sebelius had agreed to let the state provide coverage for up to 250,000 soon-to-be-Medicaid eligible Arkansans through its health-insurance exchange.
The e-mails also reveal the state Medicaid director acknowledging that expanding coverage to the state’s poor through the insurance exchange would be more expensive - at least in theshort term - than adding poor Arkansans to the existing Medicaid rolls.
The Arkansas Democrat-Gazette obtained the dozens of e-mails through a Freedom of Information Act request to the state Department of Human Services.
An improving economic outlook also colored the electronic conversations as Human Services Director John Selig proposed holding off work on a previously announced 3 percent rate cut to Medicaid providers and indicated that the state’s plan to ask the federal government for a “global waiver” has been shelved for now.
Several e-mails between state Department of Human Services officials and Surgeon General Dr. Joe Thompson involve scheduling sessions to sell the deal to key Republicans such as Sen. Cecile Bledsoe of Rogers, chairman of the Senate Public Health, Welfare and Labor Committee; Rep. John Burris of Harrison, chairmanof the House Public Health panel; Sen. Jonathan Dismang of Searcy; and Sen. David Sanders of Little Rock.
A nickname for Gov. Mike Beebe - “Beebelieber” - even surfaced.
E-mails between Beebe administration officials and Burris show an evolving “talking-point” plan in an apparent attempt to collect GOP votes.
Burris didn’t return a phone call Wednesday requesting comment.
Burris, who representsparts of Boone and Carroll counties, laid out 10 “checkboxes” in an e-mail Friday that he had discussed with state Medicaid Director Andy Allisonand Selig, referring to it as a “rough outline.”
“Flexibility of the current Medicaid system seems to be a factor in gathering votes,” Burris wrote.
Medicaid explansion needs 75 votes in the House and 27 in the Senate. Republicans control both chambers.
As way to pay for expansion, Burris’ outline proposes cuts and reductions to the state’s existing $5 billion Medicaid program that covers about 780,000 people.
The plan advanced by Burris also calls for reducing “personnel, overhead and actual enrollees” in the program and eliminating budgets for uncompensated care and Community Health Centers.
Selig’s e-mail added several bullet points to Burris’ list that the department director thought Republicans “may like,” including copays, higher reimbursement to providers from private insurers and reduced pressure on Medicaid from growing “disability rolls,” a reference to people who are Medicaid eligible because they qualify for federal Supplemental Security Income.
Burris proposed paying for the state’s share of Medicaid expansion after 2017 through cuts to the existing program and dedicating the 2.5 percent state fee on insurance-exchange policies to the Medicaid trust fund.
The proposed cuts and premium fees, Burris wrote Friday, “would provide almost enough revenue to fund the state share year to year.”
On Monday, Selig delivered a response to Burris’ “suggested talking points” to Beebe’s chief of staff, MorrilHarriman, Thompson and other advisers.
Selig cautions Burris that Medicaid expansion through the exchange depends on “market factors that are hard to predict.”
Some existing Medicaid programs would be eliminated with expansion, such as ARHealthNetworks, which offers coverage to small businesses.
Others - like aid to lowincome pregnant women and the “medically needy” or those who face huge, unexpected medical bills - would continue to exist but would likely “largely dry up” because those groups in the future will have coverage through the exchange.
The Department of Human Services had for months planned to absorb those groups into regular Medicaid expansion.
Administrative costs would be lower than through regular expansion, Selig wrote, but “probably not below existing levels.”
But Selig pushed back on the proposal to eliminate Community Health Centers and money for care for the uninsured.
“Probably not eliminated. CHCs [Community Health Centers], UAMS, Mental Health Center, etc. will all still have some uncompensated care, just not as much,” Selig wrote.
And Selig appeared cool to a recommendation in Burris’ memorandum to push for a “complete block grant” or asking the federal government for a “global waiver,” which the state applied for in October.
“We would probably not want a block grant or global waiver at this point, especiallysince we have no history of expenditures with this new population ... However, we could say that we will consider pursuing a waiver to increase stateflexibility to better manage the program.
“The Governor kept the option on the table with the Secretary [Sebelius], but we felt we needed to really think about what would be helpful to us,” Selig wrote.
The Department of Human Services had applied for a “global waiver” to allow it greater flexibility in accessing more federal dollars on the front end of an eight-year fixed-sum agreement.
But since last fall, the state’s anticipated deficit for its existing Medicaid program has been slashed from $138million to $61 million, reducing the need for the waiver, agency spokesman Amy Webb said.
Higher costs from using Medicaid dollars to pay the premiums of the newly eligible population worried U.S. Sen. Mark Pryor’s office, according to an e-mail from an aide.
The day of the announcement of the new Medicaid proposal, W. Tate Heuer, a Pryor aide, said “one significant concern I have about the workability of this proposal is it has the potential to make coverage much more expensive.”
Heuer cited a Congressional Budget Office study that estimated it would cost $3,000 more to insure the averageperson on the exchange instead of through regular Medicaid.
Allison, the state Medicaid director, replied on Feb. 27, saying the initial costsmight be higher but the longterm fiscal outlook could be better.
“We do expect the gross costs to be higher than expanding traditional Medicaid in the first years of the expansion. However, it isn’t clear that those higher costs mean that expansion turns from being a net saver to a net coster for the state in the out years (2017 and beyond)...In any event, I don’t view this option as committing the state to a more costly expansion,” Allison wrote.
The e-mails contained some joshing about Beebe, too.
“I particularly like the “Beebelieber’s” comment about “just too good to be true,” wrote Thompson after reading the governor’s comments contained in a healthcare blog post about the Arkansas deal.
Beebe spokesman Matt DeCample said he was familiar with the nickname for the governor but doubted that the governor knew its connection to pop star Justin Bieber.
“He’s not pop-culturally tuned in enough to make a connection to that little Canadian imp dude,” DeCample said.
Thompson, who accompanied Beebe to Washington, D.C., for the meeting with Sebelius to broker the agreement, referred to the “ecstatic return” of the group on Feb. 25, the day before Beebe publicly unveiled the deal.
But Thompson had a “nagging question” about what has become known as the “private option” for Medicaid expansion: how to integrate thosenewly eligible Arkansans earning up to 138 percent of the federal poverty limit of $15,415 for an individual with an ongoing effort to reduce Medicaid costs by changing the way the $5 billion program pays providers.
Allison replied on Feb. 25 that it was still unclear. But he offered a suggestion: That the state require at least some plans on the exchange to agree to follow the state’s payment program.
Providers have wondered how the state’s payment overhaul would play out with Medicaid expansion through the exchange. Arkansas Blue Cross and Blue Shield and QualChoice of Arkansas, two of the state’s largest health insurance carriers, are participating in the overhaul.
Beebe has indicated, and the e-mails reflect, an optimism that doubling the state’s exchange population will attract out-of-state insurers to dip their toes in the Arkansas market.
Ray Hanley, a former state Medicaid director for three governors who now heads the Arkansas Foundation for Medical Care, weighed in Friday saying he thought United Healthcare and Centean, an insurance company that specializes in Medicaid managed care, will “jump in” to the state’s exchange. Other large companies such as Aetna and Cigna will likely pass, Hanley predicted.
Blue Cross has planned to offer policies for the estimated 211,000 people above 138 percent of poverty, but Hanley said Blue Cross “didn’t see the Medicaid expansion rolling in [through the exchange].”
“They have decisions to make,” Hanley wrote.
Hanley also wrote that he thought the Centers for Medicare and Medicaid Services wouldn’t authorize copays to levels that many Republicans have wanted.
All depends on negotiating with the federal government about details of the deal, he wrote.
“Assume feds won’t [treat] us like they did the Indians and not honor a most clever treaty you guys hammered [out],” Hanley wrote.
Front Section, Pages 1 on 03/07/2013