Gov decides on health care exchange; more decisions still needed
November 15th, 2012
BREAKING NEWS UPDATE: Since the first broadcast of this story, Gov. Dave Heineman announced Nebraska will participate in the federal healthcare exchange. The Governor said a federal exchange would be far more affordable for the state, and would cost Nebraska about $470 million less than a state-run exchange. Check back for more on this developing story.
Meanwhile, the exchange is just one of many health care decisions Nebraska faces that could affect health care for tens of thousands of the stateâ€™s residents.
Addressing a Platte Institute meeting last week, Steve Martin, CEO of Blue Cross and Blue Shield of Nebraska, gave the audience this assessment of the Affordable Care Act, or â€˜Obamacare.â€™
â€œItâ€™s not possible to repeal it, unless someone has the magic formula here, itâ€™s just not possible. We donâ€™t have the votes in the Senate, and we have a president who would veto it. So at least for four more years itâ€™s not going to be repealed,â€ Martin said.
That means Nebraska is going to have to make some significant decisions, including whether or not to expand Medicaid. Currently, that government insurance program is mainly for the aged, blind, disabled, children in low income families and their parents. But the health care law will allow â€“ not require, after the U.S. Supreme Courtâ€™s ruling in June â€“ states to cover adults without dependent children at annual incomes up to 133 percent of the federal poverty line. Thatâ€™s about $15,000 for a single person, or $20,000 for a two-person household.
Linda Manns of Bellevue said that would be big help for people like her. â€œThat would be great â€˜cause it would be a great relief on hospital expenses,â€ Manns said. â€œI just got out of hospital like 2-3 weeks ago. And I had no coverage. So now I have to worry â€“ my husband and myself have to worry — about how are we going to pay for that?â€
Manns said she has worked all her life and always had health insurance. But then she lost her job as a certified nurse assistant, because her diabetes kept her from working the overtime her employer required. Her husband makes about $10,000 a year as a dishwasher.
So Manns said she hesitated before going to a doctor for an infected toe that had to be amputated recently. â€œI was almost going to let it go, â€˜cause I had had a prior infection in one of my toes, so I assumed it was the same thing on this toe. And I was going to say, â€˜Well, it got better last time. I really canâ€™t afford going anywhere.â€™ So I was going to put it off.â€
But then, she said, things changed. â€œIt got real bad, just overnight. And my blood sugars were running high,â€ Manns said. â€œIf I would have waited, they told me I could have lost my leg.â€
Avoiding that kind of result is one of the main goals of expanding health care coverage, according to Juliann Sebastian, dean of the University of Nebraska Medical Centerâ€™s College of Nursing.
â€œIf we make the assumption that more consumers will have access to health insurance of some kind â€“ and we donâ€™t know how many, but if we make that assumption that this will increase â€“ people will have the ability to seek care much earlier in the trajectory of potential illness,â€ Sebastian said. She said other changes in the health care system, including an increased emphasis on wellness and prevention, will help as well.
Getting patients treated earlier could help save money compared to the costs of treating those same patients under the existing system, said Dr. Ward Chambers, a UNMC cardiologist. â€œBy federal law, we can turn no one away from our emergency room â€“ nobody can. And thatâ€™s where the folks that are not insured are getting their health care,â€ Chambers said. â€œTheyâ€™re waiting until it is too late, in many cases, and seeking the most expensive health care we have available.â€
But the issue of cost has generated the most outspoken and potentially powerful opposition to the idea of the state expanding insurance coverage for poor people.
â€œWe canâ€™t afford the Medicaid expansion,â€ said Gov. Dave Heineman. He said the existing Medicaid program is already consuming a lot of state tax dollars. And he argued expanding it would take away from other things Nebraska should be doing.
â€œIf Medicaid expands, let me tell you whoâ€™s going to get hurt: state aid to the Lincoln public schools, the Bellevue public schools, the Kearney public schools; funding to UNO, UNK, the Med Center and the University of Nebraskaâ€™s going down. Or youâ€™re going to raise taxes on middle class families. And Iâ€™m opposed to every one of those (outcomes),â€ he said.
The governor cited a study done for his administration two years ago by consultant Milliman, Inc. It said the stateâ€™s share of additional Medicaid costs could add up to $766 million by the year 2020.
A UNMC study this year put the stateâ€™s cost much lower, at $168 million. And it suggested that cost needs to be weighed against benefits, including up to $3.5 billion in new federal spending in the state, which could produce more than 10,000 new jobs.
Both of those scenarios depend on the federal government living up to its commitment in the new law to pay all the costs of Medicaid expansion for the first three years, eventually phasing down to 90 percent by 2020.
But Ed Haislmaier of the Heritage Foundation questioned that assumption. â€œBasically you cannot trust that the federal government will continue with those match rates; indeed, the presidentâ€™s budget proposal for this year proposes a ‘blended’ match rate that would save the federal government money,â€ Haislmaier said.
In other words, Haislmeier suggested, over time the federal share for expanded Medicaid could drop from 90 percent towards the 57 percent the federal government pays for the existing Medicaid program.
Despite these concerns, Blue Cross and Blue Shieldâ€™s Steve Martin said deciding on expanding Medicaid is a balancing act. â€œI think the Legislature has to debate that,â€ Martin said. â€œI share some of the governorâ€™s concerns. I also share the concerns of those who donâ€™t have access to health care.â€ Martin said uninsured people â€œstill drive our costs up because theyâ€™re going to get it (health care) and youâ€™re going to pay for it anyway in the private premium.â€ He was referring to the fact costs incurred treating people who canâ€™t pay their bills wind up being shifted onto others, including those with insurance.
Despite all the uncertainty, UNMCâ€™s Ward Chambers said changes related to — and separate from — health care reform offer good possibilities. â€œâ€While thereâ€™s a lot of gnashing of teethâ€¦I personally view this as an opportunity, as a provider, to build a system that provides higher quality health care at a lower cost for our patients,â€ he said.
But even if itâ€™s easier for people to get coverage, UNMC director of health planning Fred Salzinger said not everyone will make that choice. â€œI just donâ€™t know if the people will take that level of responsibility. And weâ€™ll still have an indigent care load and they show up, not when they have a runny nose, but when they have a major episode and weâ€™ll have to care for them,â€ he said.
One thing that seems certain is the Legislature and the governor will spend plenty of time considering all this in the coming months.
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