By Jan Kaplan, Consultant, N.A.C.H.
Political analysts are now saying what health care policy wonks have been saying ever since Nov. 2. What happened in the state-level elections is a big deal for the future of health care, particularly for those most in need.
Right after the Nov. 2 elections, analysts focused their attention on the Republican gains in Congress and the implications for President Obama’s agenda. When they turned their attention to the other headline of election night – the Republican gains in state legislatures and governors’ offices, they focused on the political implications of that sea of red on the election night maps. The Republican wins warrant attention because they give the party a huge leg up in next year’s redrawing of congressional districts and, potentially, in the 2012 election cycle. But, the political junkies ignored the other big issue of the day. The Republican dominance in the states has definite implications for children’s health care.
First, let’s take a look at what happened on Election Day. The elections on Nov. 2 resulted in a power shift from Democrats to Republicans in the majority of states. Before Nov. 2, there were 26 Democratic and 24 Republican governors. Next year, there will be 29 Republican and 19 Democratic governors, with an Independent governor in Rhode Island. The outcome was similar in the elections for state legislators. Prior to Nov. 2, legislatures were controlled by Democrats in 27 states, by Republicans in 14 states and split in the remaining states. Next year, control flips to the advantage of Republicans. Republicans will control the legislature in 25 states and Democrats will be in control in 16 states. The remaining legislatures will be split. Furthermore, Republicans will control both legislative chambers and governor’s offices in 20 states, up from nine states now. So what does this power shift in the states mean for health care issues of concern to children’s hospitals and the children they serve?
First, no matter who is in charge in the states, Medicaid cuts can be expected to be on the table as states continue to face huge budget shortfalls. According to the Center on Budget and Policy Priorities, states could experience their largest-ever budget gaps next fiscal year (which begins July 1 in most states). States must, under their constitutions, balance their budgets every year, which means that the primary focus of most governors and state legislators in the coming months will be on ways to fix their fiscal crises. In at least 12 states, tax increases are presumably off the table because their new Republican governors campaigned against tax increases and they will be expected to try to keep their promises. In those states, dramatic spending cuts will be needed to achieve a balanced budget. In other states, cuts should also be expected even if combined with tax increases. Medicaid cuts will be high on the list for most lawmakers who are concerned that the program’s costs are out-of-control. In fact, the governor of Texas, is floating a proposal to opt out of Medicaid completely as a way to deal with the burgeoning costs of the program. His proposal has garnered the attention of several of his fellow Republicans.
States have very little wiggle room when it comes to finding ways to cut Medicaid spending. Provider reimbursement is often high on the target list for cuts and this year will be no exception. Unfortunately, the ongoing attack on reimbursement rates means many children and families who rely on Medicaid will find it more difficult to access the care they need when they need it.
Second, newly-emboldened Republican governors and legislators may use their states’ fiscal crises to strengthen their call for a repeal of health care reform, beginning with the Medicaid expansions in the new law. Republican governors and legislators have consistently decried the law’s Medicaid expansions, even though the expansions come with enhanced federal matching funds. The lawmakers assert that even a 10 percent state matching requirement is too large a burden for a state that faces an economic disaster.
Third, Republican state lawmakers will do what they can to delay, prevent or modify the implementation of many of the key provisions of health reform as they continue to argue for the law’s repeal. Though they must implement many of the law’s provisions, they have some flexibility in how those provisions are implemented and they may choose to opt out of certain aspects of the law.
The state-level decisions that children’s hospitals will be watching closely relate to the exchanges, as well as changes to Medicaid. The key questions for children’s hospitals include: Will the state decide to operate its own exchange or will it opt out? Will the state apply for or accept federal funds to support activities related to health reform implementation? Will the state explore participation in a Medicaid demonstration project? Will the state decide to implement new options under Medicaid, such as medical homes for individuals with chronic conditions? Will the state seek a waiver from the new law’s Medicaid requirements?
Children’s hospitals cannot take a “wait and see” position on any of these critical questions. They are already gearing up to educate new and returning governors and legislators, regardless of party, about the impact of the outcomes of these decisions on children’s health care. Children’s hospitals will be paying close attention to the actions of their state policymakers and will be at the table as much as possible to ensure that those actions work for the children they serve.