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Medicaid Expansion in Iowa

posted on April 26, 2013

Healthy decisions.  Legislators contentiously debating how to best ensure health for low-income Iowans.  We're questioning leaders of two differing views, democrat Pam Jochum and republican Walt Rogers.  And we'll give you a reporters' roundtable update on the Iowa legislative session all on this edition of Iowa Press.

Borg: Changes in how all Americans pay for health care, the Obama Affordable Care Act, is changing Iowa's methods of providing health services to those who can't afford it.  But republicans and democrats disagree on how to do it.  Generally, democrats controlling the Iowa Senate favor accepting federal money for covering more Iowans with Medicaid.  Some republicans controlling the Iowa House of Representatives are working on Governor Terry Branstad's Healthy Iowa Plan using state funds, emphasizing preventative care and covering fewer people.  We've invited two legislators managing the differing legislation.  Dubuque democratic Senator Pam Jochum spearheading expanding Medicare and Cedar Falls republican Representative Walt Rogers managing Governor Branstad's Healthy Iowa Plan.  Welcome to Iowa Press.

Jochum: Thank you.

Rogers: Thank you.

Borg: And we've got a very technical and detailed discussion here today --

Jochum: We do.

Borg: -- we want to keep it on a level, if we can, where I can understand it.  It's very technical.

Jochum: That's a good idea.

Borg: Across the table, Lee Newspaper's Statehouse Reporter Mike Wiser and Des Moines Register Political Columnist Kathie Obradovich.

Obradovich: Let's start with the basics.  You've got about a week left in the regular legislative session.  Mr. Rogers, the legislation that the Governor has proposed is in your court.  Will you be able to get done in regulation time?

Rogers: Well, we are hoping to get it out this next week, hopefully get it to full committee and run that bill on the floor.  So at that point it will go over to the Senate where Pam will take a look at it and hopefully she'll just fully agree with me and we'll go forward.

Jochum: That was a nice try, Walt.

Obradovich: And Ms. Jochum, you know, are we talking about a dream sequence here?  Is there any chance at all that you get done in the next week?

Jochum: Well, you know, we have already made a commitment that we were going to stay as long as it took to finish our business and, of course, that includes this important legislation.  It's the single biggest opportunity we've had to make sure that every Iowan has access to health.

Obradovich: Okay, well, what is the consequence if you don't get done by the end of, let's say end of June?  What happens if you don't come to a resolution by the end of June?

Jochum: You know, if we don't come to resolution by the end of June I suspect that we may go into a special session but we aren't even anticipating that at all.  We really believe we will find resolution on a number of issues including this one because it is a very important issue.  We've got 300,000 Iowans right now without health insurance.  So the proposals that we're talking about today, from our plan, would cover about half of those uninsured Iowans.  And we would do that by accepting 100% of federal funds over the next three years.

Obradovich: We're going to get into that, into those details in just a second but I just really want to get at what are the consequences of failure here?  What is at stake?

Jochum: What would be at stake is that we simply, these people will go without insurance.  I mean, the Iowa Care program expires October 31st and in both plans, House and Senate, we extend that to December 31st but if nothing passes you have 70,000 Iowans who are currently in Iowa Care who will be uninsured.

Obradovich: Okay, and Mr. Rogers, do you agree with that?  Is that the stakes?

Rogers: Except for everybody who is above 100% federal poverty level which would go into the exchange process.  But I agree, I don't anticipate us not coming to a resolution and I fully expect us to come together and figure this out for Iowans.

Obradovich: Okay.  And as far as by the end of the year, I mean, would you be prepared to come back for a special session if that is necessary?

Rogers: Oh, of course, I'd be prepared to do that.  But, again, I think we can come in, into the next three weeks or so and come to a resolution and make this happen.

Wiser: This kind of feels, though, again, on the timing -- the Governor gave his plan at the last week, the last day of the funnel.  In the House you haven't even had it brought to the floor yet, you're still in committee.  Is this too late?  It feels sort of haphazard.  Why should people be confident that this is going to be good legislation going forward?

Rogers: Well, it hasn't been haphazard to me.  I know that the Governor's people have been working on it for quite a while and so we all know that.  And I've had two extensive subcommittees on it.  We've had a public hearing.  As soon as I got assigned the bill and started working I've been working pretty hard on it.  I've talked to hospital CEOs and administrators and doctors and people on Medicaid all across the state.  And so we've done a lot of investigating as far as what we think is best for Iowans.

Wiser: Do you feel comfortable with these timelines?

Jochum: Yes, I do.  I think we will reach conclusion but obviously I believe the Senate plan is the most beneficial to the uninsured and much better for Iowa's taxpayers.

Obradovich: Let's talk about the Governor's role in this, Mr. Rogers.  When Iowa Care was created, Governor Vilsack, Governor Tom Vilsack put a lot of political capital into getting that program done.  He actually came and spoke on the floor of the Iowa House and Senate in an unusual move to explain to legislators what this plan was all about, he took legislators to Washington with him to deal with the federal regulators.  Governor -- Governor Branstad has delivered his plan fairly late, he has been out of the country.  Are you getting what you need from him as far as getting public support for his plan?

Rogers: I am getting what I need.  I agree, you know, we had the Iowa Care program but I started looking into this about a month ago and what I found was this -- I talked to people about Medicaid, I talked to people about the Healthy Iowa Plan and when I talked to people, doctors, CEOs, administrators, the discussion about Medicaid always centered around the federal money.  When I talked to people about the Healthy Iowa Plan the discussion always centered around patients becoming more healthy.  And so it hit home for me at the public hearing that we had a couple of weeks ago, that's when I had my Rocky II moment and I understood the dichotomy -- you know what a Rocky II moment is?

Obradovich: Explain.

Wiser: Explain, please.

Rogers: We've all seen the Rocky movies.  In the second movie where, you know, he's not really excited about fighting Apollo Creed and then his wife comes out of a coma and says to him, win, win this thing.  And he like changes his whole attitude.  That's when I all of a sudden realized and changed my whole continence and attitude about this whole situation when I realized people weren't excited about Medicaid expansion.  Even at that public hearing they were saying, Medicaid is not, it's inadequate, it's not a perfect system so let's take the money.

Borg: You have just opened a question that I wanted to ask and I'll ask Senator Jochum -- he has just said people generally kind of lethargic about this and I wonder, why should I be interested?  I have health insurance, you presumably have health insurance but you're a legislator, you have different interests.  But why should anybody be out watching this other than those who can't afford health care really care?

Jochum: Well, for several reasons.  First of all, we have about a billion dollars of uncompensated care in this state, which means that the hospitals are writing off bad debt and, of course, also charity care.  That in turn means that all of our insurance premiums do go up because the rates go up.  And our calculations are that those of us fortunate enough to have health insurance are paying about $1,000 more in premiums to cover that uninsured.  The expansion of Medicaid is 100% paid for.  It is great coverage.  And I've got to tell you, we started back in 2007 with bipartisan commissions of citizens and community leaders and business leaders, etc. and we already said then, we need to change how we're going to deliver health insurance in our state and in our country.

Borg: Mr. Rogers, you were going to say something.

Rogers: Yeah, well here's the issue, with Medicaid it only pays 39 cents on the dollar of reimbursement.

Borg: To hospitals and doctors.

Rogers: To hospitals and doctors.  And there's been studies that, you know, nationwide there's about $100 billion of fraud in Medicaid.  So even when you talk to people who are dealing with it they're not all excited about expanding Medicaid but when you talk to them about the Healthy Iowa Plan they go, oh, this is an option that we could actually help patients be healthier.

Jochum: Well, that's interesting because we have over 70 groups in this state who have endorsed Medicaid expansion.  The Iowa Hospital Association, the Family Physicians, Epilepsy, Cancer, Heart Association, AARP, almost every labor union, you name it, we've got over 70 groups in this state who have endorsed the expansion of Medicaid.

Obradovich: Let's compare these plans side-to-side.

Jochum: That's a great idea.

Obradovich: What I'd like to do because -- so we could not get into the weeds with a lot of details is I'm going to ask you a series of questions comparing these plans, answer as briefly as you can.  So let's start with Senator Jochum, who is covered under the expansion of Medicaid who maybe is not covered now?

Jochum: It would be any working family or individual who is earning less than $15,300 a year.  That is the people we are covering.

Obradovich: And how many people is that?

Jochum: They are working Iowans.  It would pick up 150,000 Iowans, about half of our uninsured.

Obradovich: Okay, same question to you Mr. Rogers.

Rogers: Under the Healthy Iowa Plan the same people are covered.

Obradovich: The same people.  How that -- how is is that true?

Rogers: The Healthy Iowa Plan covers up to 100% federal poverty level and then above that the insurance exchanges in the Affordable Care Act take care of the rest.

Obradovich: Okay, so and the difference with the insurance exchanges is that people will have to buy a policy.  They may get a subsidy.  Is that right?

Rogers: They'll get, yeah, they'll get a policy through the insurance exchange and those premiums, from what I understand, will actually be paid for by the federal government and then when you do your taxes at the end of the year you kind of work out how much you actually owe.

Obradovich: Okay, so it is coverage but it's not the same coverage.

Rogers: But it's an insurance -- yeah.

Jochum: It's not and I've got to tell you that if you're going to go into the insurance exchange up to 150 -- 38% of the federal poverty level, which is $15,300 a year, you have to expand Medicaid.  You have to do it even if you decide to do that piece of it that Representative Walt Rogers has just talked about.  So in order to pay for that plan the taxpayers of Iowa are going to end up with 78 more, 78 million more dollars that we've got to pay in taxes here locally --

Borg: Let me interrupt -- I'm going to get back to Kathie's who, where -- so where is the care delivered?  Same places every place, Representative Rogers?

Rogers: It's very similar. We have in our plan that your primary care has to be within 30 minutes and 30 miles of where you live.  And so virtually and potentially everywhere that Medicaid is offered can be offered in the Healthy Iowa Plan also.

Obradovich: And how is that different --

Jochum: Very much different.  As Walt has said, their plan would say 30 minutes or 30 miles from your home.  Now you're talking about people who do not have reliable transportation to begin with and quite frankly are living on the edge of just making it in life.  Under the Medicaid plan you will go to any, your hospital in your local community, a doctor in your local community, a dentist in your local community, a mental health provider in your local community.

Obradovich: And what are the differences on what can be covered under Healthy Iowa versus the Medicaid expansion?

Rogers: There isn't a whole lot difference.  The coverage is going to be pretty similar.  The Healthy Iowa Plan coverage is similar to the Medicaid and actually pretty similar to what a state employee would be, so not quite.  We're working to get it to as close --

Obradovich: And when you say not quite what is the difference?

Rogers: There are parts that I'm, that we are still working out but it's very similar as far as what will be covered.

Obradovich: And Senator Jochum, do you think that there are differences?

Jochum: There are differences.  Obviously when you get into a private insurance plan you're -- the coverage that you are going to have access to will be very limited.  I will say that I started earlier by saying that we have done this commission and we have changed how we're delivering health care in this state.

Obradovich: One last question and then I'm going to turn it over -- who pays and how much?  Mr. Rogers, who pays for the Healthy Iowa Plan and how much is it going to cost?

Rogers: It's going to cost, in our budget we have figured $162 million but only new money is $23 million out of the general fund.  And so it's not going to be a whole lot different other than there will be a small amount of --

Obradovich: Where's the rest coming from?

Rogers: -- contribution of the person in the plan and we think that is important as far as the Healthy Iowa Plan to have a little bit of investment in your own health.  The Governor may use the phrase "skin in the game".  I've talked to a lot of people on Medicaid and they have told me, well, I think it's a good thing that we have, that we pay part of this.

Jochum: Okay, so let's compare the plans in terms of price.  Just by year, the end of year one, which would be the end of 2014, the Iowa taxpayer will be on the hook for $78 million that we currently would not be under Medicaid expansion.  How do I get there?  They take $13 million from the University of Iowa Hospitals, they are scooping $44 million from 99 counties on their property taxes, they are taking $42 million from Polk County property taxes that's currently going to support Broadlawns, that is scooped and then $23 million in additional state income tax.  In addition it will cost the federal government more money because now you're subsidizing a private health insurance plan.  So you're actually adding about $200 million to the national debt under the other plan than under Medicaid expansion.

Wiser: I want to circle back to something that was mentioned before.  Senator Jochum, you brought up these groups that are, have supported Medicaid expansion and all the polling that I've seen has been for expansion of Medicaid.  Representative Rogers, how do you explain to these people who seem to want this expansion that they're not going to get it?

Rogers: I think it comes down to -- Medicaid expansion simply pays hospital bills and they see the raw dollars and they go, okay, we can pay our bills with this money.  The Healthy Iowa Plan actually focuses on the patient being more healthy and is a plan that uses ACO's, the Accountable Care Organizations, it works with health coach, it specifically talks about --

Wiser: But were is the demand for the Healthy Iowa Plan other than from the legislature?

Rogers: The demand is that people want to be healthy.  The demand is this is a plan that it's not the same old, same old Medicaid expansion, Medicaid plan and every time people talk about it, oh, okay, Medicaid, yeah, I don't hear anybody going, I want to expand that.

Borg: Well, pardon me --

Rogers: It's a plan that helps people be healthy.

Borg: Pardon me if I'm somewhat astonished here that earlier in the program both of you said, we expect that there will be agreement.  Man, listening to you here I don't see any agreement.

Jochum: This is where the agreement is at -- in our bill we have already incorporated a change of how health care will be delivered in our state under Medicaid and under the private insurance.  That's part of ACA but it is also incorporated and so we are focused on medical homes, which means now you have a team approach of trying to keep people well and to prevent an illness.  So we are changing the entire delivery of the health care system.  ACO's are at least five years away before they are fully implemented in this state.

Borg: Are you saying that is a middle ground?

Jochum: We have already agreed to all of it.  That has been agreed to in both plans.

Rogers: I would say in the Senate plan, their plan studies those ideas, our plan implements it.  ACO's are farther along --

Borg: I'm asking where is there going to be agreement?  Are we going to have a hybrid plan between Medicaid expansion and the Governor's plan?

Rogers: I don't know where we'll have agreement in the end game.  That is yet to happen.

Borg: But you're predicting agreement.  What are you willing to give?

Rogers: I'm willing to -- I'm not going to give on the idea that this plan is one that focuses on patients being healthy.  We talked about ACO's.  We talked about delivery system.  We talked about care coordination.  That is implemented in our plan.  Theirs is just kind of studies and talks about it.  So that is one thing that I think is integral in this moving forward is patients being healthy, our plan focuses on it 100%, helps deliver it right away.

Wiser: You keep saying your plan but this is the Governor's plan, we haven't seen the House plan yet.  Is there -- does there need to be some bridges gapped among the House caucus?  Is the property tax portion a problem?  What are the problems with getting this forward?

Rogers: There are some issues that we're still kind of working out but I think the biggest thing -- when I said I had the Rocky II moment, that's when I embraced the idea that this plan really focuses on people being healthy.

Obradovich: Are you going to have problems with your caucus because of concern about the federal funding for abortion?  Is that going to be a road block that derails this whole discussion here --

Rogers: There is no funding for abortion in the Healthy Iowa Plan.

Obradovich: No, but there -- Medicaid discussions sometimes expand to cover anything related to health care.  So you're not going to have any problems at all as far as that issue on this bill --

Rogers:  I anticipate that discussion will be in the HHS budget discussion and --

Borg: The Health and Human Services.

Rogers: Yes.

Obradovich: Which also has money for Medicaid, for the existing program, correct?

Rogers: Yes.

Obradovich: Okay.  And is that something that you are factoring in to your discussions here towards the end as well?

Jochum: In terms of the budget bill itself or into the --

Obradovich: In terms of how -- money for health care for Iowa.

Jochum: It should not be a part of it.

Wiser: Speaking of money for health care, the big complaint, the overreaching argument is that you can't trust the federal government, they're broke, why saddle them with this plan?  Senator Jochum, what is your answer to that?  Why do you trust the federal government?

Jochum: Not true.

Wiser: Not true.

Jochum: First of all, Medicaid has been in existence for 50 years and I will admit that there's been times that the federal government, as well as the state government, has reneged on some of its promises on funding.  But the Medicaid program, Medicaid is one program they have not reneged on.  It started out being an insurance plan to cover people with a disability, our grandparents and parents who are in nursing care, those kinds of things and for the extremely poor of our society.  So no, it has not.  The second things is, we put an opt out provision in our plan that if for any reason the federal government reneged we would get out of it and we would go into a different alternative plan.

Borg: Speaking about getting out of it, I have to get out of this right now.

Jochum: Okay.

Borg: It's an interesting discussion, very important but we're at the end of our time.

Jochum: You're kidding.  Are you sure?

Borg:  We'll have you back.

Rogers: We need more time to discuss this one.

Jochum: We do.

Borg: Thank you.  And we'll be continuing Iowa Press in just a moment with a reporters' roundtable.

Borg: Contact the Iowa Press staff online at our website or email us at iowapress@iptv.org.

Borg: Continuing Iowa Press, Associated Press Government and Politics Reporter Catherine Lucey.  Catherine, you heard Representative Rogers and Senator Jochum express optimism that they're going to reach agreement on some way to cover low income Iowans with health care.  I was skeptical.  How did you read it?

Lucey: I have to agree.  I think Representative Rogers referenced the Rocky movies, I kind of feel like we've hit the point you get to in every movie where you see absolutely no way out for him, that he can't possibly win the big fight.  And, of course, we haven't gotten to the end yet.  So maybe there is a resolution but I'd have to say from where we sit right now it's sort of hard to see what the deal is.

Wiser: Now, they have a little leeway on this because they're not restricted necessarily by the calendar.  You heard them bring up a special session.  They do have two key dates that they have to meet though.  On June 30th they have to have their waiver request in to Health and Human Services and they have to have a program or funding for a program in place no matter what that is by the first of the year.

Obradovich: You know, the one week deadline is when legislators stop getting paid.  It's not necessarily when they go home.  And there's a lot of work to be done on the budget and other top issues and so it's possible that they could work this out along the way.  However, there are some significant differences here.  They may agree on how they want the health care plan in Iowa to look maybe sometime in the future but who pays for it is the big impasse here and I don't really see yet where the solution is.

Borg: Catherine, she's right.  Time is running out here in the legislative session and there are a number of priorities, property tax reform, education reform, what are we going to do about low income health care.  What is going to get done?  What is likely?  Anything there?

Lucey: Well, I think a lot of people are looking specifically to education reform as sort of the first big piece of this puzzle.  It is a key priority for Governor Branstad.

Borg: But is it one or the other -- do they all depend on each other or are they acting independent?

Lucey: No, not necessarily.  But, I mean, the Governor has very clearly laid out that he'd like to do things sort of in order the first thing being education reform and that is the issue that they have moved the furthest on in terms of legislative timing.

Borg: What is delaying education reform?

Lucey: Well, right now I think there are a couple of key differences between the sides in terms of how you structure some of the reforms.  The democrats really want a plan that requires a certain number of changes to the way teachers are paid.  The republicans want those things to be optional.  There is also potential for some conflict over proposals from the republicans on removing some of the regulations and oversight for homeschooling.  And so these things are not yet worked out but -- and there hasn't been much action in the past week but it certainly seems possible that it will, they will get a resolution because there's a lot of funding that plays into this that the schools really want.

Borg: Yes.

Wiser: One of the members of the conference committee, this is a ten member conference committee charged with making a deal on education reform, said the issues now are home school and home rule.  That was Sharon Steckman who said this, which is they haven't met this last week, maybe next week they'll get moving at the beginning of the week.

Borg: Well, go a little bit further.  Politics of that, home school to home rule.

Wiser: In the House plan there is -- there are some home school provisions that reduce some of the requirements for people who choose to home school their children and actually other children.  That is something that some republicans are insisting on.  Democrats don't like those as much.  And there is also -- home rule is what is the authority that school districts should have as compared to the state and that goes into testing and teacher evaluations and a host of other issues.

Borg: Kathie -- go ahead.

Obradovich: With those issues I think that there is opportunity for them to find middle ground either by doing something that is small, smaller than they expected or they throw those pieces over the side and decide to study them.  A lot of times what you see is the answer to those policy question is we're going to study this for a year.

Lucey: Set up a committee, yeah.

Borg: Go ahead.

Lucey: Well, but also they haven't met publicly this past week but there may have been some private conversations and I think in terms of what this means for the overall session I think a lot of people are looking to see if they can find some resolution on this, it bodes well for some of these other big issues.

Borg: Kathie, I was going to ask you and I tried to interrupt you just a moment ago, the Senate race, Senator Harkin's.  There's no republican in yet.  What's going on?  And is it kind of an ice jam right now?  Is Steve King icing it all?

Obradovich: Well, I would say that yeah, Steve King has to thaw out first before the rest of this can flow and a lot of people are still waiting for his decision.  Obviously he was out here a couple of weeks ago and we thought it was going to be soon, like maybe by the end of the month but he has delayed wild speculation about will he or won't he at this point.  In the meantime, Lieutenant Governor Kim Reynolds, who we thought was going to wait for Steve King, got tired of waiting apparently.  She said, nah, not going to do this.  She may run for Governor at some point and we're starting to hear some other names now, people who are sort of getting into the mix.  And I don't think that process is over yet.

Wiser: You know, the presumptive republican, sorry, democratic nominee is Bruce Braley, the first district congressman, democrat.  That opens up his seat and there's another election story that is kind of going on here is who is going to run for that.  We have former House Speaker Pat Murphy from Dubuque who has said he wants the seat.  We have some republicans, Steve Rathje, Robert Blum and this week we heard that Swati Dandekar, former state Senator who is now on the Utilities Board, has set up a website and the website if you see it, it just says Swati for Iowa Coming Soon.  So that gives some indication that maybe she'll be out there.

Borg: How much longer can all of this wait on the republican side, Catherine?

Lucey: You know, they're saying, oh we have time, it's not until next year but the longer you wait, the weaker your position is.  Braley is raising a lot of money, he is a very high profile figure and he is already, he's going to be a formidable candidate.  So it behooves them to get someone set up as soon as possible.

Borg: I'm going to circle back because you're spending a lot of time at the legislature.  Give us a predicted date in your mind, when are you predicting that they're going to adjourn?

Lucey: Well, I'm predicting June 6th because my birthday is June 7th and I want to celebrate.

Borg: I hope you're able to do that.  Thanks for being with us today.  Thanks for all your optimism.  We'll be back next weekend with another edition of Iowa Press, same times, 7:30 Friday night, noon on Sunday.  I'm Dean Borg, thanks for joining us today.


Tags: Democrats government health care Iowa legislature Medicaid news Pam Jochum politics Republicans Walt Rogers