In Oregon, Medicaid expansion notches another win at the polls

Last spring, Oregon legislators were weighing the idea of ending their Medicaid expansion to close a growing hole in the state budget. This would have made Oregon the first state in the country to back out of the Affordable Care Act program expanding coverage to millions of low-income Americans.

Instead, the state ended up doing something different: Voters approved Tuesday a tax on hospitals and health insurance plans to continue the Medicaid expansion’s financing. The tax could raise as much as $320 million over two years. This is the first such measure approved by voters anywhere in the country. But it’s also the second time that the Medicaid expansion has won at the polls: Maine voters in November overwhelmingly supported bringing the Medicaid expansion to their state.

I’ll be curious to see if any other states follow in Oregon’s footsteps. I haven’t heard any rumblings about financing challenges for the Medicaid expansion elsewhere. Most Medicaid expansions appear to rely on general revenues rather than dedicated taxes. But this measure’s success in Oregon may catch the eye of other states with difficult budget situations as a way to bring in additional revenue.

The Trump administration has opened the door to work requirements in Medicaid, approving a Kentucky plan to begin in July.

Mississippi recently submitted a request to set up a similar work requirement. The state already has some of the tightest Medicaid eligibility requirements in the country. The program does not cover childless adults. For parents, it will only cover adults who earn less than 27 percent of the poverty line — $5,600 for a family of four. This is the 48th lowest Medicaid eligibility threshold in the country (Missouri, Idaho, and Texas have slightly lower limits).

Mississippi is in a significantly different situation than Kentucky, which, relatively speaking, has higher-income Medicaid enrollees. Because it participates in the Affordable Care Act’s Medicaid expansion, Kentucky covers adults (both parents and non-parents) up to 400 percent of the poverty line, about $34,000 for a family of four.

Here’s what Georgetown’s Joan Alker, one of the smartest Medicaid experts I know (follow her on Twitter!) says about the Mississippi waiver:

These families are living in deep poverty and already facing many challenges. Housing instability is very high in this income bracket – if families aren’t literally homeless they are often doubled up with family or friends and living on the edge.

Using the numbers provided in the Mississippi application, we estimate that enrollment will decline by approximately 5,000 persons in the first year of the demonstration. We assume the decrease in enrollment is either because individuals now enrolled will be disenrolled, or because individuals who would otherwise enroll will not do so because they cannot meet the work requirement or are deterred by it.

I found this pair of charts shared by Sarah Wakeman, an addiction medicine physician at Mass General Hospital in Boston, to be a fascinating picture of what the opioid crisis in West Virginia currently looks like.

It shows that doctors’ prescriptions for opioids have declined in recent years. Physicians really do seem to be getting the message that, for chronic pain, opioid painkillers are often not a good treatment option.

While that’s a promising sign, it doesn’t seem to be stemming the opioid crisis. Instead, the state has seen a recent surge in deaths from non-prescription opioids. This is especially true for heroin and fentanyl.

As Dr. Wakeman points out, it’s “worth comparing slope of line of heroin and fentanyl deaths to amount of prescribed buprenorphine,” a medication-assisted treatment for opioid addiction. Buprenorphine prescriptions have essentially been flat in West Virginia as fentanyl deaths skyrocket — a worrying sign that the some providers are still hesitant to prescribe the drug.

This story appears in VoxCare, a newsletter from Vox on the latest twists and turns in America’s health care debate. Sign up to get VoxCare in your inbox along with more health care stats and news.