As Mississippi lawmakers look for compromise between widely differing House and Senate Mississippi Medicaid expansion plans, experts with a health research group have projected the costs, savings and efficacy of the plans and offered a third, potential compromise plan.
The analysis shows that under each plan, the state would see net annual savings – ranging from tens of millions to hundreds of millions of dollars – by expanding the state-federal Medicaid program to cover working, poor and uninsured Mississippians. The plans, the study says, also vary widely in how many Mississippians would be covered – from around 50,000 to nearly 200,000.
The study was commissioned by the Center for Mississippi Health Policy and conducted by the Hilltop Institute at the University of Maryland, Baltimore County. Hilltop has studied Medicaid expansion nationwide and recently testified before the Mississippi House Medicaid Committee.
“We wanted to get some updated numbers based on publicly available data,” said Morgan Henderson, director of analytics and research for Hilltop. “We really want to make sure folks having these discussions have data points they need.”
The study takes the House and Senate plans at face value, even though both contain elements not likely to be approved by the federal Centers for Medicare and Medicaid Services. The Senate plan, for instance, includes a stringent work requirement for coverage that, besides potentially costing millions in administrative fees, isn’t likely to be approved by CMS.
Both the House and Senate plans contain another potential poison pill that could prevent expansion from being implemented. They have 12-month moratoriums on people who qualify for the expanded Medicaid coverage from dropping private coverage and applying for Medicaid. CMS is highly unlikely to approve this, and such moratoriums would probably not meet constitutional muster in a court.
The options
Mississippi Senate plan
One striking difference between the Senate plan and the House and compromise plans is the Senate one would turn down about $1 billion a year in federal money to cover more expansion costs. It also would forego nearly $700 million over the first two years in enhanced federal funding that some refer to as a “signing bonus” for states that fully expand Medicaid per the federal Affordable Care Act.
The Senate plan would provide coverage to people making up to 100% of the federal poverty level – about $15,000 a year for an individual. Hilltop estimates this plan would cover about 54,000 people, although Senate leaders said they estimate about 40,000 people would sign up.
The Senate plan would require participants to work 120 hours a month or be enrolled as a full-time student or in a workforce training program. It would exempt some from this requirement, including parents of children under 6, people mentally or physically unable to work or those who are caregivers to disabled family members.
Cost
The state’s upfront cost of the Senate plan would be paid by a 3% tax on Medicaid managed care providers.
Hilltop estimates the Senate plan would cost the state a little over $114 million per year, including $15 million in administrative costs. But when these costs are offset by the tax on providers, the economic stimulus of expansion and other offsets or revenue, Hilltop estimates a net savings to the state of $43.4 million a year.
Mississippi House plan
The House plan would provide Medicaid coverage for people making up to 138% of federal poverty level, a little more than $20,00 a year for an individual. Hilltop estimates this would cover about 134,000 Mississippians (again, factoring in the “moratorium” on leaving private coverage).
The House plan calls for work requirements – 20 hours a week or enrollment as a student or in workforce development – but would still go into effect without the requirements if CMS fails to approve them.
Under this plan, Mississippi would draw down about $1 billion a year in increased federal Medicaid payments, and over the first two years, another nearly $700 million in enhanced federal payments.
Cost
The state share of upfront costs for the House plan would be covered by a 4% tax on Medicaid managed care providers.
Hilltop estimates the House plan, with no work requirement approved, would cost a little over $115 million, including $8 million in administrative costs. But when these are offset by the tax on providers, economic stimulus and other offsets or revenue, Hilltop estimates an annual savings for the state of more than $404 million a year for the first two years, then $79.5 million a year for the third year and beyond.
House Speaker Jason White and others have noted that the enhanced federal payments to the state totaling nearly $700 million over the first two years would cover all state costs for the first four years of the House expansion plan. White also noted that the House plan, even if a work requirement is not approved, would require the managed care organizations to track employment and other data from those covered.
Compromise ‘hybrid plan‘
Hilltop’s “Mississippi MarketPlus Hybrid Plan” would offer expanded Medicaid coverage through the state’s managed care program for those making under 100% of the federal poverty level. For those making 100% to 138% (up to $20,000 for an individual) of poverty level, the plan would use federal money to provide assistance for them to buy private insurance plans through Mississippi’s marketplace exchange.
Hilltop estimates this plan would provide coverage for 197,000 Mississippians.
The plan would require managed care companies to provide employment support and require mandatory referral to workforce training. It would also require those covered to pay marketplace insurance co-pays, but would not include a work requirement or moratorium on people leaving private insurance.
Like the House plan, this plan is expected to qualify the state for enhanced federal Medicaid payments and the two-year “signing bonus” of nearly $700 million.
Cost
The plan, like the Senate’s, includes a 3% tax on Medicaid managed care providers to help cover state costs.
Hilltop estimates the upfront cost to the state for this plan would be a little more than $186 million, including $12 million in administrative costs (including work support). But these would be offset by the tax on providers, economic stimulus from expansion and other offsets or revenue. Hilltop estimates a net savings to the state for this plan of more than $356 million a year for the first two years, then $31.3 million a year in savings for years three and up.
The Hilltop study also noted this plan would allow the state to receive a 90% federal match for services currently funded only with state dollars, including hospital services for incarcerated people and some behavioral health services.
Other findings
Hilltop’s report says that Medicaid work requirements – when they were previously allowed by the feds – have not shown to increase workforce participation. It said, “Moreover, the Arkansas experience demonstrates that the administrative burden in reporting work status can lead to Medicaid coverage loss for the working poor – thus hurting the exact individuals designed to be covered under work requirements.”
A Georgia program similar to the Mississippi Senate’s plan in several regards, has shown that stringent work requirements result in low enrollment and high administrative costs, the Hilltop study notes. As of recently, the Georgia program had enrolled only a few thousand people and over 90% of its costs to-date have been administrative costs and consulting fees. Georgia is still battling the federal government in court over its work requirements.
The Hilltop study found the Senate’s plan “contains high budget risk” to the state. Since the plan eschews extra federal funding available for expansion, “if enrollment exceeds estimates, there would be proportionally greater budget overruns in the Senate version than the alternative plans.” It noted that to protect state coffers, language could be inserted to the House or hybrid plan that rescinds the expansion should the enhanced federal match drop.
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