Affordable Care Act/Medicaid Expansion

Health Care For All

After drastic cuts were made in Missouri’s Medicaid program in 2005, Women’s Voices began advocating for quality, affordable health care for all.  In January, 2007 we learned about the Massachusetts initiative to provide health care for all their residents and in March, 2007 we stated our position, saying in part that:

Every resident of Missouri deserves to have access to adequate, affordable health care. Providing such a network of care would be a wise investment in the state’s future, benefiting all Missourians, including aging adults, working parents, individuals with disabilities, and the mentally ill.  We called for affordable health services for all Missouri’s children, including prevention services.

See the right column for programs on health care for all, the Affordable Care Act and Medicaid Expansion.  

Key Health Care Questions to Watch

published in the St. Louis Post-Dispatch July 8, 2018 (originally from Washington Post)

1. How are the Obamacare marketplaces shaping up for next year?

Expect a rather convoluted debate over this question, as Democrats are now focused on highlighting any and all premium hikes so they can blame Republicans during the election season for trying to sabotage the Affordable Care Act. Republicans are either trying to ignore the whole debate or casting blame on Democrats for passing the ACA in the first place.

It’s true the administration has taken some steps that could certainly weaken the marketplaces, including revamping rules around how they work and expanding the availability of association and short-term health plans that could lure healthier consumers. Some top insurance executives have warned the administration is making it increasingly difficult for them to survive in the marketplaces.

Yet there are also some signs that bluer skies are on the way next year.

Insurers are still in the middle of filing their proposed 2019 rates, but the hikes look less dramatic overall compared to this year, according to a recent analysis by the Kaiser Family Foundation. So far, we’ve seen only a handful of rate increases of more than 20 percent and a few cities — including Minneapolis, Richmond and Indianapolis — may even experience some rate decreases.

Additionally, the Congressional Budget Office has projected the average premium for a mid-level ACA marketplace plan will increase by about 15 percent next year, compared to an average 34 percent increase this year.

None of the plan prices will be finalized until shortly before open enrollment begins Nov. 1, but expect lots of political debate around rates during the fall election season.

2. Will Medicaid work requirements bite the dust?

The big, outstanding way the Trump administration is seeking to remake the Medicaid program — by allowing states to impose work or volunteering requirements on able-bodied enrollees — is in doubt, after a federal judge last week blocked Kentucky’s effort toward that end.

The case won’t be over anytime soon, as the Department of Health and Human Services is almost certain to appeal that ruling. But the decision does cast a dark cloud over other states also pursuing these “community engagement” requirements.

Three additional states — Indiana, Arkansas and New Hampshire — have already received federal approval for similar program changes and seven others, including Arizona, Kansas, Maine, Mississippi Ohio, Utah and Wisconsin, are awaiting a response from HHS.

Here’s the key question at stake: Does adding work requirements help states furnish medical assistance to their residents? If the administration can’t explain how these requirements would further the aims of the Medicaid program, it might have trouble getting buy-in from judges.

3. What’s Congress going to do on health care before the midterm elections?

The short answer: Probably nothing.

Some conservatives are trying to infuse new life into Obamacare repeal-and-replace efforts, via the health-care plan Heritage and Co. released last month. And Sens. Ted Cruz (R-Tex.) and Lamar Alexander (R-Tenn.) tried to gauge their colleagues’ interest on a slew of different policy measures — many of them health-care related — with a survey they recently circulated among GOP members.

But lobbyists say the talk of more attempts to pass health-care legislation is mostly hype. A package of measures to combat the opioid epidemic stands the best chance of final passage (the House approved a batch of bills last week), as lawmakers want to leverage the issue for political gain in November. But Democrats in the Senate would almost certainly block anything else related to Obamacare or abortion rights, and Republicans aren’t likely to venture there anyway as they try to retain control of Congress.

Department of Justice Won’t Defend Pre-Existing Conditions Provision of ACA

June 8, 2018

The Justice Department announced  that it won’t defend a core ACA provision in court: the guarantee of coverage for preexisting conditions.  The department essentially agreed that recent legislation has voided most of the ACA’s most important provisions.   Read more here

New Executive Orders on Health Care

On October 12, President Trump issued two new executive order aimed at changing the rules for health insurance.

  1. First, the President issued an Executive Order aimed at allowing insurance companies to sell cheap, junk insurance plans that are exempt from important consumer protections. These plans can discriminate against people with pre-existing conditions, and they don’t have to offer comprehensive coverage.Experts fear these plans will lure healthy people away from high quality insurance with the promise of cheap premiums. As a result, more people will be vulnerable to financial devastation if they suddenly become ill or injured. And, anybody who isn’t in perfect health will face quickly-rising premiums for the insurance plans that can’t discriminate against them.In short, the Executive Order would lead to a two-tier health insurance system: One that sells cheap but skinny plans to people who are currently healthy, and one that sells increasingly expensive to the rest of us – anyone who isn’t in perfect health.
  2. Later that night, President Trump announced that he will halt cost-sharing subsidies that help insurance companies lower deductibles and other out-of-pocket costs for low-income Americans.Experts and elected officials from across the political spectrum agree that this will lead insurance companies to raise premiums even further, and may even lead more insurers to leave the Marketplace. The announcement comes less than three weeks from the start of Open Enrollment for 2018 plans.

What Consumers Need to Know

Most people who buy their health insurance through the Health Insurance Marketplace, you should be worried, but not panicked. Here are some things to know:

  • President Trump’s Executive Order on junk insurance plans will need to go through months of rule-making and public comments, so it will not take effect immediately.
  • By law, insurance companies have to continue providing discounts on out-of-pocket costs like deductibles to those who qualify. If you’re getting these discounts, they will continue. The insurance company won’t get paid back, however, which is why we expect companies to compensate by raising premiums for everybody.
  • If you qualify for premium discounts, those discounts are safe and will hold your premiums steady. Because the price you pay is tied to your income, you will be insulated from premium hikes.
  • If you don’t qualify for premium discounts, you will pay the price for these reckless decisions. Already, insurance companies in many states had filed huge rate increases because of concerns that the Trump administration would stop the cost-sharing reduction payments. Please be sure to contact your members of Congress and tell them how you will be personally impacted by premium increases of 20% or more. 


Important Factors in Health Care Reform

Provided by Missouri Health Advocacy Alliance

1. Medicaid– Though most rural residents are in non-expansion states, a higher proportion of rural residents are covered by Medicaid (21% vs. 16%).
Any federal health care reform proposal must protect access to care in Rural America, and must provide an option to a state to receive an enhanced reimbursement included in a matching rate or a per capita cap, specifically targeted to create stability among rural providers to maintain access to care for rural communities. Enhancements must be equivalent to the cost of providing care for rural safety net providers, a safeguard that ensures the enhanced reimbursement is provided to the safety net provider to allow for continued access to care. Rural safety net providers include, but not limited to, Critical Access Hospitals, Rural Prospective Payment Hospitals, Rural Health Clinics, Indian Health Service providers, and individual rural providers.


2. Market Reform– Forty-one percent of rural marketplace enrollees have only a single option of insurer, representing 70 percent of counties that have only one option. This lack of competition in the marketplace means higher premiums. Rural residents average per month cost exceeds urban ($569.34 for small town rural vs. $415.85 for metropolitan).
Any federal health care reform proposal must address the fact that insurance providers are withdrawing from rural markets. Despite record profit levels, insurance companies are permitted to cherry pick profitable markets for participation and are currently not obliged to provide service to markets with less advantageous risk pools. Demographic realities of the rural population make the market less profitable, and thus less desirable for an insurance company with no incentive to take on such exposure. In the same way that financial service institutions are required to provide services to underserved neighborhoods, profitable insurance companies should be required to provide services in underserved communities.


3. Stop Bad Debt Cuts to Rural Hospitals – Rural hospitals serve more Medicare patients (46% rural vs. 40.9% urban), thus across the board Medicare cuts do not have across the board impacts. The fact that according to MedPAC “Average Medicare margins are negative, and under current law they are expected to decline in 2016” has led to 7% gains in median profit margins for urban providers while rural providers have experienced a median loss of 6%. Congress must stop bad debt cuts for rural hospitals.


A look to the Past…..

The ACA Is Here To Stay!   

June 25, 2015

Joyce Borgmeyer, chair of the Women's Voices Health Care Committee

Joyce Borgmeyer, chair of the Women’s Voices Health Care Committee

The Supreme Court ruling maintaining subsidies to offset the cost of health insurance “was a huge win,” according to Robert Gatter, St. Louis University School of Law.  At a celebration of the ruling at Central Reform Congregation June 25, Gatter said that the court did the right thing by interpreting the intent of the statute.   The purpose of having “an exchange established by a state” was to support health insurance markets, not destroy them.   And by allowing consumers who earn 100-400% of poverty to purchase insurance on an exchange, regardless of whether it is run by a state or the federal government, supports health insurance markets.


Tom and LaDonna Applebaum

Tom and LaDonna Applebaum


LaDonna Applebaum stood with Women’s Voices member Melanie Shouse in front of the office of Representative Lacy Clay advocating for the creation of the Affordable Care Act.  Melanie, under-insured, was diagnosed with stage 4 breast cancer and died in 2010.  But while battling her disease she worked tirelessly for health care for all.   LaDonna said, “Because of Melanie, I am here today.”

LaDonna and her husband Tom purchased insurance on the exchange and received their health card January, 2014.  In June, Tom had an accident requiring surgery on his hand.   In August, LaDonna was diagnosed with breast cancer.   She has completed her chemo therapy and radiation treatments.  And for those who claim she and Tom are “takers”, she says, “We’re not takers; we’re giver backers!”  They hope to earn enough next year to not require a subsidy.

Steven Engelhardt, Communication Director for Representative Lacy Clay, read a statement from the representative.  Rep. Clay said that he is gratified that the essential funding mechanism which has provided insurance for 16 million Americans is now the “settled law of the land.”   Clay encourages us to use this win as an incentive to work with our state legislators to expand Medicaid and stop allowing 5.4 million dollars to be lost each day by refusing the federal funds.  Clay says it is “time for our legislators” to provide the same insurance they receive to the 200,000 Missourians who fall into the coverage gap.