Cumberland County commissioners ask Toomey to keep Medicaid expansion in Senate health bill

June 16--The Cumberland County Commissioners sent a letter Wednesday to U.S. Sen. Pat Toomey warning against any attempt by Republican senators to roll back funding for expanded Medicaid coverage.

The growth of Medicaid access has "proven to be especially crucial as our county struggles to respond to the current opioid epidemic," the commissioners wrote.

Toomey is one of a group of GOP senators working on revisions to the American Health Care Act, the bill passed earlier this year by the House of Representatives as a "repeal and replace" measure to reform the Obama-era Affordable Care Act.

One of the biggest criticisms of the AHCA, as passed by the House, is the proposed rollback of Obamacare's Medicaid expansion, which saw the federal government shoulder nearly all of the cost if states agreed to expand their medical assistance programs.

Prior to the Obama expansion, such programs were offered only to certain groups, such as the disabled, as well as those living below the poverty line. Since Pennsylvania opted into the expansion in 2015, Medicaid is available to all citizens making 138 percent or less of poverty income. Under Obamacare, the federal government initially paid 100 percent of the cost for this expanded population, and will fund 90 percent after 2020.

This expansion has seen 12,240 Cumberland County residents gain insurance through Medicaid. Further, 2,359 of those patients have used the county's mental health and substance abuse services, and 619 have used those services specifically for opioid addiction, according to data from the Cumberland-Perry Drug and Alcohol Commission.

If the Senate were to pass the AHCA as written by the House, the federal government would cease to fund the expansion at a 90 percent cost share, and instead fund it at the pre-expansion rate, which averages 57 percent depending on the state. This would drastically increase the states' share of the cost to maintain the expansion, almost certainly causing states to cut Medicaid coverage.

This would then put the county in the lurch to pay for county-administered treatment out of the county's general fund, in situations where patients no longer have Medicaid coverage that is providing reimbursements to county health agencies.

Prior to 2015, the county often had to cut off service after its budget ran dry, but this has not been the case since Medicaid coverage increased.

"If our state had not opted into MA [medical assistance] Expansion, our county drug and alcohol department would certainly not have been able to cover the cost of treatment for those low-income county residents with the limited, capped funds we manage," the commissioners wrote.

"Prior to the MA Expansion, funds earmarked for rehabilitation and halfway house services were usually exhausted partway through the fiscal year," the letter continued.

Cost

The total cost of services for the Medicaid expansion population in Cumberland County was $8.4 million over the past two years, of which $3.1 million was related to opioid treatment, according to figures from the drug and alcohol commission.

The rollback of the Medicaid expansion would allow Republicans to repeal the Obama-instituted surtax on investment income that funded the expansion. According to estimates from the Congressional Budget Office, this would cut $346 billion in taxes on investors and the financial services industry over the next 10 years, an important part of the GOP's deregulation agenda.

Further, Toomey noted in a statement that Medicaid costs are growing in what he projects to be an unsustainable manner -- Medicaid funding now accounts for 10 percent of the entire federal budget. Toomey has proposed pegging Medicaid spending increases to inflation.

But for county governments, this seems like yet another program that state and federal governments create, and then slowly pull the rug out from underneath, shifting the cost back onto a less diverse tax base.

At the same time taxes are being cut at the federal level, the local level is faced with either the impact of increased taxes, or cuts to vital services. The county's ability to raise money to backfill federal reductions is also limited, given that the county has a much narrower scope of taxing powers than state or federal authorities. The only sure-fire method is to raise property tax rates, which are already a subject of concern.

Cutting Medicaid expansion funding "would have a huge negative impact on counties, especially when it comes to our mental health and drug and alcohol services," Commissioner Jim Hertzler said.

The commissioners' letter concludes by stating that the Medicaid expansion "has given our county a fighting chance" in the opioid addiction crisis, and imploring Toomey to "make sure it continues to be part of our health care system."

At the very least, however, the Senate's version of the AHCA will likely differ from the House policy in the speed at which Medicaid expansion dollars are rolled back.

The House version called for the expansion cost-sharing to be slashed in a single year, something that Toomey and other senators have said is too abrupt and should be done over a period of several years to allow the market to adjust.

The House rollback "probably is a little too sudden, and that is problematic for many state budgets, so I'm open to that conversation about easing the transition, but I think the transition has to happen," Toomey said.

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