A number of Republican-led states face potential political battles this year as they try to pass Medicaid expansion plans.
Almost 30 states and Washington, D.C. have already expanded Medicaid, and now Indiana, Tennessee, Utah and Wyoming are considering expansion in one form or another.
Tennessee's proposed pilot program
In Tennessee, Gov. Bill Haslam (R) has proposed an alternative Medicaid expansion plan, a two-year pilot program called Insure Tennessee. But Republican leaders have expressed concern with Gov. Haslam's plan.
"It's just that a lot of us are getting cold feet real quick. I have grave reservations," Tennessee House Republican Caucus Chairman Glen Casada (R-Franklin) told The Tennessean.
Tennessee Senate Speaker Ron Ramsey (R-Blountville) was more optimistic in his comments, which were used in a Nashville Post report.
"When a state has an opportunity to take power away from the federal government and institute real conservative reform, that is an opportunity that must be taken seriously. Governor Haslam has negotiated a deal which returns tax dollars back to Tennessee while using conservative principles to bring health insurance to more Tennesseans," he said.
There are two options for coverage under Insure Tennessee: the Volunteer Plan and the Healthy Incentives Plan.
Under the Volunteer Plan, employees who aren't financially able to enroll in their employer's health insurance plan may use vouchers to pay insurance premiums and "other out-of-pocket costs in connection to the privately offered insurance," according to The Tennessean.
The concept of the Healthy Incentives Plan involves assisting enrollees in creating a health savings account, which builds up when enrollees practice "healthy behaviors" such as receiving preventive services, the report reads.
Last month, the Tennessee Hospital Association agreed to help pay for the proposed Insure Tennessee plan. Under the deal, the THA will fund Tennessee's contribution, according to NPR.
Craig Becker, who heads the THA, said in the NPR report, "We basically left over $800 million on the table in federal dollars. Which is a lot of money that could’ve done a lot of different things," referring to when Gov. Haslam was deliberating about whether to accept federal Medicaid money tied to the Patient Protection and Affordable Care Act.
"We've all been telling him, look, we're stressed. Each individual hospital has come to him and said, look we're gonna have to lay people off. We've seen layoffs. We've seen hospitals close. We're not just crying wolf here."
State legislators plan to discuss the proposed Insure Tennessee plan during the upcoming special session, which is scheduled to begin on Feb. 2.
Indiana's alternative plan
In Indiana, Gov. Mike Pence (R) is looking to expand the Healthy Indiana Plan, a state-sponsored health insurance program administered by private health insurers, as an alternative to expanding Medicaid under the PPACA, according to a report from The Advisory Board Company. The proposed plan, called HIP 2.0, is a consumer-driven healthcare coverage program for low-income adults, according to a news release.
Gov. Pence has requested the waiver for HIP 2.0. However, it is yet to be seen whether it will be issued or denied by CMS, according to The Journal Gazette. But there could be a potential battle if the state and CMS aren't able to come to terms, the report reads.
Brian Tabor, vice president of government relations for the Indiana Hospital Association, told The Journal Gazette, "We’re going to do all we can to urge everybody forward."
HIP 2.0 would be fully funded through Indiana's existing cigarette tax revenue, hospital assessment fee program and federal Medicaid funding.
Members with incomes greater than 100 percent of the poverty level would be required to contribute to a Personal Wellness and Responsibility Account (similar to a health savings account) to help pay for their deductible.
As of October 2014, the plan was expected to cost $18 billion — of which the state will pay $1.5 billion — through 2020.
Utah's proposed plan
In Utah, Gov. Gary Herbert (R) has proposed his alternative Healthy Utah plan, which would be a three-year pilot program. However, the plan already had a setback when Utah Legislature's Health Reform Task Force decided not to recommend the plan to the full Utah Legislature, "instead picking two other options to cover many fewer (residents), and only if they are 'medically vulnerable,'" according to The Salt Lake Tribune.
Rep. Jim Dunnigan (R-Taylorsville) described it in the report as a "good, measured approach."
But David Patton, executive director of the Utah Department of Health, said in the report that he was hopeful the full Utah Legislature will support Healthy Utah.
The Healthy Utah plan would be available to people earning up to 138 percent of federal poverty level, as well as those in the coverage gap, that is people who don't qualify for Medicaid but earn from 49 percent to 100 percent of the federal poverty level, according to The Salt Lake Tribune.
According to the report, Utah would pay $4.6 million for half a budget year in 2016 and then $80 million to $90 million per year by early in the 2020s.
Wyoming's plan that could pop up again
And in Wyoming, the Wyoming Department of Health has proposed the Wyoming Strategy for Health, Access, Responsibility and Employment, or SHARE, Medicaid expansion plan. That plan was rejected by the Labor, Health and Social Services Committee, a joint interim committee of the Wyoming Legislature, but could pop up during the Wyoming legislative session, which will convene Jan. 13, according to the Casper Star-Tribune.
Wyoming Sen. Charlie Scott (R-Casper) has also proposed an alternative Medicaid expansion plan, which is based on Indiana's Medicaid program and was approved for consideration by the Wyoming Legislature, according to a Casper Star-Tribune report.
The plan would need a waiver from the federal government because it requires recipients to contribute an amount into a personal health and wellness account, according to a Wyoming Tribune-Eagle report.
Those earning between 100 and 138 percent of the poverty level would lose coverage if they don't make the required contributions, the report reads.
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