1. Expanding Medicaid will cost Arizona hundreds of millions of dollars.
For the first three years, the federal government has promised to cover 100% of the medical costs for the newly eligible Medicaid enrollees, and yet the cost to Arizona’s General Fund for the first year alone would be $154 million. The costs to the state are a result of the fact that the federal reimbursement rate of 100% applies only to the direct medical expenses of the newly eligible enrollees, not the additional administrative costs. Additionally, the 100% reimbursement rate does not apply to those new enrollees who were previously eligible but either did not know it or otherwise failed to enroll.
The true costs to Arizona have been hidden by projections that reflect only the first three years of the expansion, not the later years when the state’s share increases. The Kaiser Family Foundation estimates that the total cost to Arizona for 2014-2019 could be as high as $739 million depending on how many newly eligible people enroll.
2. A supermajority vote is required to authorize new taxes.
In 1992, Arizona voters passed Proposition 108, which requires approval of 2/3 of both chambers of the Legislature to impose a new tax or fee or to increase an existing tax or fee. There is a narrow exception for “fees and assessments that are authorized by statute, but are not prescribed by formula, amount, or limit, and are set by a state officer or agency.”
The proposed Medicaid expansion disregards the spirit and letter of the law. Because the Governor’s office has explicitly prescribed the assessment amount in the proposed budget, the tax increase doesn’t fall within the exception in the law.
If legislators authorize a provider tax by a simple majority vote, they will circumvent the will of the voters and will be vulnerable to a lawsuit that, if successful, will leave the legislature with an expensive Medicaid expansion that lacks a funding mechanism.
3. The federal government is unlikely to maintain promised funding rates.
President Obama has already proposed cutting the promised reimbursement rate to states in his last two budgets.
The Governor’s office has acknowledged that Washington will likely cut its promised funding level. A publication released from the Governor’s office in January entitled Difficult Choice: Expanding Adult Medicaid Coverage states “it is probable that, at some point, the federal government will choose to reduce reimbursements to the states as a consequence of its own fiscal challenges.” In fact, the circuit breaker, which is intended to protect Arizona from additional costs, is not activated until the federal government cuts the reimbursement rate for the newly eligible enrollees to less than 80% - effectively allowing the federal government to double Arizona’s share of the costs before the state would react.
4. The provider tax, which is the proposed funding mechanism for the expansion, could be limited or eliminated.
A provider tax is a scheme by which states tax healthcare providers in order to draw down additional federal matching dollars. The tax paid by healthcare providers is returned to them via increased Medicaid spending in the state or increased Medicaid reimbursement rates to providers.
There are growing calls from both sides of the aisle in Washington to limit or eliminate the ability to assess a provider tax. Attacks have come from President Obama, Majority Whip Durbin (D-IL), Senator Corker (R-TN), House Republicans, and the Simpson Bowles Commission. If the provider tax is limited or eliminated, Arizona will be left holding the bill.
Eliminating or limiting the provider tax will not trigger the circuit breaker despite the fact that it would leave the expansion in place with no funding source besides the general fund.
5. The circuit breaker may not be enforced by a future governor and future legislature.
The circuit breaker is designed to automatically abolish the Medicaid expansion if the federal reimbursement rate for the newly eligible enrollees ever falls below 80%.
If circuit breaker is triggered, the sitting governor and legislature would face a media storm as thousands of people who had become dependent on free government health care were removed from the Medicaid rolls. Arizona has already experienced such a media storm when the state did not drop coverage, but merely froze enrollment for childless adults up to 100% of the federal poverty level in 2011.
6. The Woodwork Effect is likely to be much larger than anticipated.
The federal health care law’s higher reimbursement rate does not apply to the costs associated with those individuals who are newly enrolled but who were previously eligible – this is referred to as the “woodwork effect.”
When Arizona passed Prop 204, it was estimated that roughly 129,000 people would fall into this category. But by 2003 it was approximately 250,000 – almost double the original estimate, costing the state hundreds of millions in unexpected money.
7. Uncompensated care is unlikely to decrease.
The Governor’s office has stated that uncompensated care results in a hidden tax of $2,000 per family per year that is reflected in the family’s insurance premium. Proponents of the expansion claim that it will solve the problem of uncompensated care and eliminate this hidden tax.
The same claims were made by proponents of Prop 204, but neither claim proved true. Uncompensated care increased by an average of 9% a year during the first seven years of the Prop 204 expansion according to a study by the Lewin Group. And the average family premium increased from $8,972 in 2003 to $14,854 in 2011 – a 66% increase. There is no reason to believe the results will be different this time.
8. Cost projections are likely incorrect, as Arizona’s last Medicaid expansion illustrates.
The Prop 204 expansion was four times more expensive than the projected cost each year. For example, in 2008, the cost of covering the Prop 204 population was projected to be $389 million, but the cost was actually $1.623 billion.
9. There is no rush because a state can choose to expand Medicaid at any time.
The Centers for Medicare and Medicaid have made it clear that states may opt into the Medicaid expansion at any time. It would be wise for Arizona to wait and see how the expansion plays out in other states before committing Arizona to an expansion that will be incredibly expensive and difficult to roll back.
10. There is no such thing as free federal money.
This “free federal money” is borrowed money which taxpayers must pay back.
By agreeing to the Medicaid expansion, Arizona legislators would be committing current and future Arizona taxpayers to billions of dollars in new federal debt, and each Arizona legislator who votes for the expansion will be complicit in Washington’s spending problem.