Category: MM Curator

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: CO hopes to use a new provider tax scheme to fund fixes to its abysmal BH services for vulnerable kids. The new plan would cap the “admin” vig of the magic money funds at 15% of “assessments” and then slough off the rest to help address BH needs. So, the leftovers.

 
 

Clipped from: https://thenevadaindependent.com/article/expanded-hospital-tax-could-boost-medicaid-rates-fund-behavioral-health-services

 
 

The entrance to Mountains Edge Hospital in Las Vegas on April, 19, 2019. (David Calvert/The Nevada Independent)

Nevada’s lack of state-supported services for child mental health issues has been described as a “crisis” — underscored by a federal investigation last year revealing that the state’s lack of adequate treatment and services to children and youth with behavioral health disabilities likely violated federal law.

But under a little-noticed bill that would allow private hospitals to implement an existing “provider tax,” state health officials are hoping to leverage up to $30 million in new state funds to address a lack of youth behavioral health resources. The initial funds could potentially grow to an estimated more than $100 million after the money is matched by the federal government in support of new Medicaid services and rate increases for behavioral health.

The proposed measure, SB435, would build upon an existing framework that grants private hospitals the ability to vote for a state-assessed “provider tax” of no more than 6 percent, earmarked as supplemental Medicaid payments as part of a federal dollar-matching program. The bill passed unanimously out of its first committee and has received an exemption from legislative deadlines.

The bill would also align state law with federal requirements by ensuring that tax proceeds are not solely used to offset tax payments made by the providers. Money generated could be used to fund supplemental Medicaid payments, enhance reimbursement rates and pay for state administrative costs to implement the new tax. The specifics of who receives the new payments outside of those paying the tax must be outlined in the poll issued by the state to determine whether there are enough votes to support the implementation of the tax.

One of the proponents of the measure, the Nevada Rural Hospital Partners, said the bill aims to fill the gaps in payments to providers and grants Medicaid the ability to address any unintended financial consequences that may stem from the new “tax” and Medicaid payments.

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“SB435 ensures that our small Critical Access Hospitals in Nevada won’t be unintentionally harmed by the implementation of the provider fee,” said Blayne Osborn, president of Nevada Rural Hospital Partners. “Beyond that, the bill puts forward critical funding to support behavioral health providers in Nevada, which our rural communities desperately need and our hospitals fully support.” 

Though administrators and proponents of the measure describe it as a “provider tax,” it acts more as an assessment, allowing the state to pay the private hospitals more money for Medicaid services with the caveat that a provider is not being guaranteed by the state that they will receive sufficient payments to offset taxes paid as necessary to avoid federal scrutiny.

One of the proponents is Gov. Joe Lombardo. While on the campaign trail, he promised not to raise taxes, and a spokesperson said SB435 does not undermine that vow.

“Senate Bill 435 advances an existing framework that private hospitals were authorized to seek in 2017, and critically, it does not raise taxes or require a two-thirds vote at the Legislature,” Lombardo spokesperson Elizabeth Ray wrote in an emailed statement.

Under an amendment proposed by Lombardo’s office and brought by the state Department of Health and Human Services, the measure would direct the agency to pull no more than 15 percent of what is collected from the “provider tax” for administrative costs. Any remaining money collected for administrative purposes would need to be set aside for future Medicaid expenditures aimed at supporting “behavioral health care for recipients with serious behavioral health conditions and psychiatric disorders.”

That amendment is a direct response to come into compliance with federal disabilities law after the publication of the October report from the Department of Justice finding that Nevada does not provide its children with behavioral health disabilities adequate community-based services and unnecessarily institutionalizes children, sometimes out of state. 

The report indicated that more than 1,700 Nevada children were admitted to a hospital for psychiatric care in 2020, and that same year, more than 480 children received services in residential treatment facilities — places the state reported where children remain an average of nine to 12 months, sometimes longer.

Data gathered as part of the reporting process revealed that most children in residential care did not receive state behavioral supportive services, and less than a fifth of the children who were hospitalized for psychiatric care in 2020 received wraparound care coordination from the state. Findings also showed the state relies on residential treatment facilities in and outside of Nevada to treat children with behavioral health disabilities.

“Nevada has a history of leaving mental and behavioral health behind or on a bus to another state,” Children’s Advocacy Alliance lobbyist Lea Case said during public testimony. “We support this first step while recognizing that there will still be a need for increased and sustainable funding to address the shortcomings noted in the DOJ report.”

Lombardo’s proposed budget shows the “provider tax” is estimated to bring in more than $388 million annually in new state revenue, with 15 percent allocated for administrative costs and any remaining funding within that percentage going toward behavioral and psychiatric services. The state estimates that this new state revenue could result in about $850 million to $1 billion in total for new supplemental Medicaid payments to private hospitals in Nevada. 

Director of Health and Human Services Richard Whitley said he estimates that 15 percent of the proposed “provider tax” would generate about $30 million for behavioral health, specifically, which can be matched with dollars from the federal government. The match could more than double or triple the money for behavioral health services, he said, potentially generating more than $100 million for behavioral health care in Medicaid.

“This will benefit both adults and children and reduce impact on the hospitals and the crisis services that are currently being provided in our emergency rooms,” Whitley said during a mid-April hearing on the measure.

 
 

Nevada Department of Health and Human Services Director Richard Whitley speaking with Assemblywoman Sarah Peters (D-Reno) in the Legislature in Carson City on February 8, 2023. (David Calvert/The Nevada Independent)

Nevada Medicaid Administrator Stacie Weeks said the state hopes to implement the tax by January 2024 and estimated it would support about 55 private hospitals within Nevada.

“It will create new supplemental payments, inpatient and outpatient, in addition to state-directed payments in our managed care program,” Weeks said during the hearing.

Though the budget includes estimations and projections related to the “provider tax,” a more detailed model of the finances and program, as well as the total funding generated, is expected to be available in June if the bill passes. Representatives of the Nevada Psychiatric Association, legal services providers, Clark County and the Nevada Republican Club testified in support of the proposed bill at its hearing last month.

Background and a future vote

The proposed bill takes advantage of a law passed under Republican Gov. Brian Sandoval during the 2017 legislative session that allows for a provider fee or tax program, as long as it is developed in collaboration with a majority of providers from medical facilities such as doctors’ offices, hospitals or other licensed medical offices, or an agency providing personal care assistance services. 

As part of the 2017 law, the provider tax program would be developed at the request of a group of providers and could proceed only with the approval of a supermajority vote of the providers (67 percent) within the group. Once that happens, the state division of Health Care Financing and Policy is given regulatory authority to assess and run a provider fee or tax program.

Whitley said the state’s low Medicaid rates have contributed to an overall provider shortage, and the “provider tax” will help address the shortage by ultimately bringing in more Medicaid dollars. He and other presenters said that the state will treat the proposed provider tax as a contract with the hospitals and, when voting, all hospitals will receive every detail related to the tax, including how the funding will be used and the tax percentage.

“The hospitals have to agree to participate in this,” Whitley said, adding that the provider tax under the new bill could also help public rural hospitals by opening the door for supplemental Medicaid payments to those hospitals in the event that something changes within the Medicaid structure as a result of the new private hospital tax.

The Nevada Hospital Association brought forward the request for the provider tax, the outlines of which were detailed in a public workshop held earlier this year by the Division of Health Care Financing and Policy.

A spokesperson for the association said all Nevada health care providers, including hospitals, are underfunded by Medicaid. In the past 20 years, she said hospital Medicaid rates have only increased 5 percent overall though hospital costs have increased approximately 50 percent, and additional funding is needed to preserve and sustain Medicaid services.

“We support the administration’s efforts to bring more funding through Medicaid provider fee programs,” said spokesperson Jeanne Corbit. “And we are working with the administration and lawmakers to craft legislation that sustains and improves access to hospital services.”

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: CO’s resuming of PA rules for medically complex kids support is quite disruptive.

 
 

 
 

Clipped from: https://coloradosun.com/2023/05/10/medicaid-in-home-nursing-care-children/

Parents of children with disabilities so severe they say they need round-the-clock care to live at home are growing increasingly frustrated with the state Medicaid division as confusion over policy changes has dragged on for months. 

Families of children who need breathing and feeding tubes to survive say they’re again receiving denials for in-home nursing services after the latest freeze on the prior-authorization process was lifted. 

“The law hasn’t changed. The criteria hasn’t changed,” said Jack Robinson, an attorney representing 20-25 families who have appealed the denials they received from the Medicaid division. “The only basis to reduce a child’s hours is if they got better. In none of the situations that I’m dealing with have they gotten better.” 

Department officials say only a fraction of the 948 people who’ve asked for private-duty nursing services have been denied the benefit or had their hours cut. And families are still receiving services while they appeal.

The confusion goes back to three years ago, when the Colorado Department of Health Care Policy and Financing — which includes Medicaid — put a freeze on the prior-authorization process for in-home nursing care for children and kept the freeze throughout the coronavirus pandemic. That meant families were receiving services based on physicians’ orders but without having the state contractor that processes claims making a determination about whether they were medically necessary. 

In the meantime, Colorado switched to a new contractor. Kepro, a national company, handles prior-authorization requests submitted by agencies that supply private-duty nurses.

After the pandemic shutdown ended and the prior-authorization process resumed in November 2021, so many families were denied services or had their children’s hours reduced that the state department again put the prior authorization process on a freeze. Some families told The Colorado Sun they were in panic mode for months until the department initiated the emergency freeze last October. 

But the prior-authorization process is back on again, and denial and reduction letters began hitting mailboxes in March and April, setting off a new wave of frustration.

Families upset over recent denials

Pam Rogers said services were cut by 14 hours per week for her 9-year-old daughter who uses a wheelchair, cannot communicate and survives with a gastronomy tube for nutrition. Rogers adopted the girl so she didn’t have to spend her life in a hospital. 

“She has comorbidities in literally every system of her body,” Rogers said. “If someone is not assessing her comfort, pain, red marks on her side. … all of these little things can turn into very big expensive things and potentially fatal things.” 

In addition to the girl, Rogers has a biological daughter who choked and suffered a brain injury at age 2. She also adopted four other medically fragile children from foster care, including a baby who was living in a hospital.

The Aurora mom fears the ongoing denials for families like hers will lead to fewer options for medically fragile children. 

“They are making it incredibly hard on a daily basis to care for them,” Rogers said. “They are adding 100% more stress than is ever needed. Every single time we feel like we resolve one thing, they try to break another thing. They just keep placing more barriers and more barriers to the point I don’t know what the future holds.” 

Robinson said he is representing several families who have been denied or partially denied nursing services and are appealing to an administrative law judge. “Medicaid benefit is a property right,” the attorney said. “They are in essence taking away that property right without a change in circumstances.” 

Robinson said a few of the children, who are only 2 or 3 years old, did not previously have to go through a prior authorization because of the freeze on that process. But several of his clients were approved in the past and have now been denied the same level of in-home services. 

The parents, some of whom have set up licensed medical foster homes and adopted children from the foster care system who were abandoned in hospitals, believed they would receive services for the rest of their lives, Robinson said. 

“The whole idea is that we are trying to set up a home setting that would provide these incredibly medically fragile, complicated kids with nursing services,” he said. “Now all of a sudden the whole landscape changes. We can’t send the child back to the hospital.” 

Katerina Evers and her husband, both nurses, have adopted eight medically fragile children. Two were dropped from 24-hour nursing services to zero hours, the couple learned at the end of April. 

“It’s like they are playing with people’s lives.”

— Katerina Evers, mother of eight medically fragile children

One of those is a 16-year-old girl who has a g-tube, oxygen, a wheelchair and behavioral issues because of previous abuse. She had been approved for round-the-clock services for the past 11 years, since she was adopted by the Evers from an abusive home, Evers said. 

The other is a 9-year-old girl whom the Evers adopted as an infant. The child’s face and neck were not formed correctly and she needs an artificial airway to breath and a tube to eat because of a cleft palate. Evers said she received a letter from the state contractor saying the girl’s services were not medically necessary because she is “in a state of transition.”

“What transition would that be?” Evers asked. “She has been like this since infancy. The letters make no sense.” 

She wonders why the Medicaid division can’t grandfather in the families who already had 24-hour services and enact its policy changes in the future.

“It’s like they are playing with people’s lives,” she said. 

About 200 denials issued since November 2021

From November 2021 to last month, 948 people applied for private-duty nursing services. In 86.5% of cases, families were fully approved for services, according to Medicaid officials.

But there were 71 full denials and 134 partial denials issued during that time. 

Denials happen because the services aren’t deemed medically necessary or for technical reasons, meaning that more information about their needs is required. 

Since last fall, Medicaid officials have provided additional training about the prior-authorization process to the 30 or so agencies in Colorado that place private-duty nurses in homes. The state also worked with its contractor to write clearer denial letters that provide an explanation and describe a family’s right to appeal. 

In addition, the Medicaid division met with disability advocacy groups to hear their concerns, and reached out individually to families who had complained publicly about denials. 

“While you may have a few voices that are really loud, we really wanted to understand the scope of the over 900 people that receive this benefit,” said Bonnie Silva, the director of the Office of Community Living at the state health care department. “Let’s make sure we understand all of the problems.”

At the same time, the Department of Health Care Policy and Financing is reviewing the rules around private-duty nursing, which have not been updated for several years. There is no rule, for example, dictating how many medically fragile children one nurse can care for at a time. The department is holding a series of public meetings and plans to present proposed rules to its rule-making medical services board in early 2024. 

We’ve worked hard to err on the side of the member, err on the side of how do we be really cautious and make sure that our policies don’t result in harm.

— Bonnie Silva, Office of Community Living

The private-duty nursing program cost $113 million in 2022.

Silva said that any child who in previous years had been approved for services through the prior-authorization process but had their services deemed “not medically necessary” in the latest process was automatically approved by the department “while we take more time to look at those.” 

Some families, however, told The Sun that they are panicked because they believe they have been denied or might be denied after such a review. 

It’s not the goal of Medicaid for anyone to lose services, Silva said. 

“We’ve worked hard to err on the side of the member, err on the side of how do we be really cautious and make sure that our policies don’t result in harm, while also having some fidelity to the responsibility that we have that is extraordinary around the funding that we receive,” she said.

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: In which Maine considers stopping a provider tax scam. I have never heard of this happening, and am doubly amazed that CMS actually put it in its sights a few years ago. Wonders never cease!

 
 

Clipped from: https://www.maine.gov/dhhs/blog/tackling-long-standing-financing-issue-mainecare-2023-05-10

May 10, 2023

Among other provisions, the Governor’s budget change package proposes to eliminate a disputed tax that funds Medicaid (i.e., MaineCare) services, to limit the State’s liability going forward and clear the path for payment rate reform. This reflects Governor Mills’ commitment to responsible State budgeting and support for MaineCare which provides vital services to residents with health and long-term service and supports needs. 

Maine’s Service Provider Tax was created in 2004 and applies to some health providers, among other entities. Some of the revenue supports MaineCare services. According to KFF’s State Health Facts, 48 states had at least one provider tax as a financing source for Medicaid in 2022. 

In a September 2018 letter, the federal Centers for Medicare & Medicaid Services (CMS) raised concerns about the Service Provider Tax’s application to private non-medical institutions (PNMI) and similar home- and community-based providers in Maine. CMS asserted that this health care tax was an impermissible source of the non-federal share of funding that is used to finance Medicaid services. CMS relied, in part, on a July 25, 2014 State Health Official letter (PDF), that cautioned states against selectively taxing Medicaid managed care organizations (“MCOs”). However, the affected providers in Maine are not MCOs. Additionally, Maine’s Service Provider Tax is not on the federal government’s list of either prohibited or permitted provider taxes and the Department has argued that it meets the tests set forth for other types of permissible provider taxes. 

As Maine sought clarification, in November 2019, the Trump Administration proposed the Medicaid Financial Accountability Regulation (MFAR) that would have made major changes to provider taxes and supplemental payments – preventing Maine from developing a path forward in light of the uncertainty, as explained in a report to the Legislature (PDF). Although the federal government withdrew this proposed rule in the fall of 2020, in December 2020, CMS initiated a compliance action on the State of Maine by “deferring” or delaying payment of federal funds associated with the questioned tax effective back to July 1, 2020. Such deferrals, which are the first step toward a penalty or “disallowance,” continued quarterly and totaled $28.5 million as of April 2022.  

The Department appealed the deferrals. If a disallowance is issued, Maine could also appeal it. However, few administrative appeals are successful and the process is lengthy. Without repealing the Service Provider Tax on health providers, the potential disallowance from the federal government could be over $100 million through this fiscal year, with approximately $34 million more each subsequent year.  

As such, the change package proposes to repeal the Service Provider Tax on health providers and remove all documented add-on amounts associated with the tax that are built into MaineCare reimbursement, effective January 1, 2025. The change package would use nearly $20 million in ongoing general funds from the updated May 2023 revenue forecast to replace the lost revenue that supports MaineCare services. Additionally, the change package would add a one-time $6.5 million to the Medicaid Stabilization Fund in the event that CMS issues a disallowance for past use of the tax, bringing the total in that Fund to $29 million.  

Repealing the health components of the Service Provider Tax would solve a dispute that dates back years. Consistent with facilitating re-certification of the Riverview Psychiatric Center and paying the federal disallowance incurred under the previous administration, Governor Mills is addressing this long-standing issue, not passing it along to future administrations. The change package would improve fiscal responsibility and the financing of MaineCare.  

It is also consistent with Maine’s award-winning comprehensive rate reform system. Under PL 2021, Chapter 639, MaineCare is working toward rates that are based on adequate, equitable and data-driven reimbursement; reward quality, cost-effective care; promote accountability for cost and performance; and reduce administrative burden. The providers currently paying this tax have had or are scheduled for a comprehensive review and update of how MaineCare reimburses them. The proposed change takes another step toward rates that meet the reform law’s goals. 

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: The NY Medicaid budget will hit $100B for the first time. To infinity and beyond!

 
 

Clipped from: https://www.empirecenter.org/publications/budget-deal-increases-state-share-medicaid-spending-by-14-percent/

(This post has been updated to correct errors.)

Albany’s newly enacted budget appears to increase the state share of Medicaid spending by $4.2 billion or 13 percent, continuing a trend of explosive growth for the safety-net health plan in the aftermath of the pandemic.

Governor Hochul’s initial proposal in January had called for an unusually large increase of $2.9 billion or 9 percent. Her final deal with the Assembly and Senate – approved this week – would add another $1.3 billion, according to projections in a “scorecard” prepared by the Budget Division.

Overall spending on Medicaid, including federal aid and funding from New York City and the 57 counties, is expected to break $100 billion for the first time in the year ahead.

The program’s outlays dropped during the pandemic’s first wave in fiscal 2021, but bounced back sharply after that – in part because of a big increase in enrollment during the public health emergency (see chart). The state’s share is on track to be 53 percent higher in 2024 than it was in 2019, which compares to 10 percent growth in the five years before 2019.

 
 

This trend has pumped billions more into what was already a costly health-care system by national and international standards. New York spends more per capita on Medicaid – and on health-care generally – than any other state.

Here are some of the key Medicaid- and health-related provisions of the new budget:

Across-the-board rate increases: The bulk of the added spending will go toward higher fees for various groups of providers that treat Medicaid recipients.

Hospitals are due to receive bumps of 7.5 percent for inpatient care and 6.5 percent for outpatient care, which will cost the state an estimated $395 million in the first year.

Nursing homes and assisted living providers were allocated a 6.5 percent increase, at a cost of about $217 million, with the option of a 7.5 percent increase if approved by the health commissioner, the budget director and federal officials.

The budget also includes a 5 percent cost-of-living adjustment for workers in group homes and other facilities funded by the Office of Mental Health and the Office for People with Developmental Disabilities.

Distressed hospitals: The final deal added back $500 million in supplemental funding for financial distressed and safety-net hospitals, partially restoring a $700 million reduction in Hochul’s original proposal.

Pharmacy ‘carve-out’: After three years of delay, the final budget allows the state to move ahead with a restructuring of Medicaid’s pharmacy benefit that was approved in 2020.

Under this so-called “carve-out,” which took effect April 1, prescription drug costs will be directly reimbursed by the Health Department rather than by the insurance plans that process most other claims under Medicaid managed care.

The state expects this will save $410 million, mostly through additional rebate payments from drug manufacturers. However, most of that savings is to be paid back out to safety-net providers – to compensate them for lost revenue they have been generating through a federal drug-discount program called 340B. 

Cost-shift to counties: Lawmakers agreed to phase out an aid-sharing arrangement that reduces the Medicaid tab for New York City and the other 57 counties – effectively ending a freeze on the local contribution that has been in place for eight years.

As a result, the city and counties will pay $219 million more in this fiscal year, rising to an estimated $808 million by 2027.

For counties outside New York City, that additional cost is equivalent to 4 percent of their property tax revenues in 2021.

Home health compensation: In an unexpected last-minute provision, the budget calls for cutting wage supplements for downstate home health aides by $1.55 per hour.

At the same time, a $1 hike in the enhanced minimum wage for home health aides, which was due in October, would be replaced by a $1.55 hike in January. In New York City, Long Island and Westchester County, that would precisely offset the $1.55 cut to the wage supplement – meaning the downstate workers’ total minimum compensation would stay flat in the new year.

The wage supplements, instituted in 2016, require that downstate home health aides receive extra compensation on top of the minimum wage which can be provided either in the form of benefits, such as health insurance, or as straight wages.

The hourly amounts are currently $4.09 in New York City and $3.22 in Nassau, Suffolk and Westchester counties, and would drop to $2.54 and $1.67, respectively, as of Jan. 1.

This change was backed by the union 1199 SEIU because part of the savings would go to a subsidy for home health agencies that offer health insurance for their workers. This would mean more revenue for an 1199-operated benefit fund that has been losing money for several years.

However, most aides currently receive all or most of the supplements in the form of wages rather than benefits – and the policy change amounts to a net reduction for the affected workers as a group.

Over the first two years, the state projects that it will save $584 million on wage supplements while allocating just $157 million for enhanced subsidies – for a net reduction of $427 million compared to the baseline. The total impact for workers would be larger, because the reduction in wage supplements affects their compensation from all payers, including Medicare and private sources.

Health-care capital grants: The budget allocates another $1 billion for capital grants to health-care institutions – allowing hospitals, nursing homes and other providers to expand or renovate their facilities at taxpayer expense.

Lawmakers have previously approved similar pots of money seven times over the past 10 years – allocating a total of $5.4 billion, less than half of which has been spent.

Extension of HCRA taxes: In what has become a routine step, the budget extends a pair of multi-billion-dollar taxes on health insurance for another three years, to March 2026. 

The taxes have been levied under the so-called Health Care Reform Act since 1996. Together, they bring in about $5.2 billion per year, making them the state’s third-largest source of revenue after income and sales taxes.

They also add hundreds of dollars per year to the cost of health insurance for the average family – which is one reason New York has some of the highest premiums in the contiguous United States.

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: More details on the current left wing Medicaid expansion offensive.

 
 

 
 

Clipped from: https://www.politico.com/news/2023/05/09/medicaid-for-undocumented-immigrants-democrats-00095949

The intra-party debate comes as the Biden administration and Democrats at the national level grapple with how to expand health care access for noncitizens.

 
 

“It frustrates me because it’s not based on any kind of policy decision other than dollars,” said Connecticut state Rep. Jillian Gilchrest, a Democrat who is spearheading a bill to expand Medicaid to all undocumented kids this year. “The budget document outlines your priorities as a state. As we’re looking at all the various things we need to fund, this should be top of mind.”

The intra-party debate comes as the Biden administration and Democrats at the national level grapple with how to expand health care access for noncitizens — who make up just 6 percent of the U.S. population but 23 percent of the uninsured — in a divided Congress.

Hopes of a public health insurance option, a hallmark of Biden’s presidential campaign, were dashed during debates over what became the Inflation Reduction Act. Instead, House Republicans just passed legislation that would add work requirements to Medicaid — a move that could leave an additional 600,000 Americans uninsured, according to the Congressional Budget Office.

Against that federal backdrop, progressive state lawmakers are trying to take up the mantle, using their own dollars to push policies for undocumented immigrants that were until recently outside mainstream Democratic thinking and inch toward universal coverage.

“The idea that health care is something everybody should have access to has shifted in the last decade or so,” said Kelly Whitener, an associate professor at the Georgetown University McCourt School of Public Policy’s Center for Children and Families. “How to get there is the hard part — and I think the cost barrier is a real one.”

In Nevada, Democrats have slashed a $300 million proposal to expand Medicaid to all undocumented immigrants to a $90 million policy that would cover those up to age 26 — with further cuts on the table. Even if legislators can agree on the price tag, Republican Gov. Joe Lombardo has not said whether he will sign it into law.

In Minnesota, where Democrats control the governor’s mansion and both chambers of the legislature for the first time in a decade, lawmakers are debating whether to extend state-funded Medicaid coverage to undocumented children or spend an extra $39 million to cover all undocumented immigrants as they balance a host of other priorities, such as K-12 schools, affordable housing and child care.

And in Connecticut, lawmakers in 2021 expanded Medicaid coverage for undocumented children up to age 8. Last year, they expanded the program to age 12. While a bill was introduced this year that would have allowed coverage up to age 26, costing the state about $15 million a year, it was whittled down to age 15, at a cost of $3 million.

Immigrant advocates — frustrated with the state’s incremental approach to expanding coverage — are pushing in the final weeks of the legislative session for an extra $5 million they say would allow them to cover all kids up to age 18. Connecticut Gov. Ned Lamont, a Democrat, said during a Wednesday forum that he was comfortable with extending the program to age 15.

“Well, the advocates are saying, ‘Not enough,‘” Lamont said. “I get it. That’s their job, but I think we’re making progress every day.”

Democrats who favor incremental coverage expansion argue they are being methodical and chafe at the accusation that it signals a lack of political will.

“That’s just flat out nonsense,” said Connecticut state Sen. Cathy Osten, the Democrat who co-chairs the legislature’s appropriations committee. “We just want to roll out the program correctly.”

Illinois offers a cautionary tale for those concerned about costs. The number of undocumented adults who have signed up for Medicaid under the state’s coverage expansions exceeded the actuarial firm Milliman’s projections, according to the Department of Healthcare and Family Services. And, according to the state’s most recent public data, between March 2022 and February 2023, the program paid nearly twice — $189 million more — in claims for covered adults than Milliman projected, the department said.

“There’s historically been an assumption that takeup would be slow and low, that people won’t necessarily know that coverage is available, or if they are aware that coverage is newly available, they might be reluctant to enroll,” Whitener said. “But it is not playing out that way in every state.”

Beyond Illinois, California, Maine, Massachusetts, New Jersey, New York, Oregon, Rhode Island, Vermont and Washington state have all expanded Medicaid to undocumented children. Some of those states also provide benefits to adults, either through Medicaid or the state health insurance exchange. Undocumented immigrants, as well as legal immigrants who have been in the country for less than five years, do not qualify for federal Medicaid money.

And Utah’s GOP legislature this year passed a bill expanding health coverage to undocumented kids through its Children’s Health Insurance Program after it was amended to include a $4.5 million cap, data review requirements and a sunset clause. Rep. Jim Dunnigan, a Republican, said he helped kill the proposal last year, but after extensive conversations with the bill’s Democratic sponsor, he co-sponsored the legislation this spring and shepherded it through the House, where it passed 64-7, with 52 Republicans in support.

“Some of my more conservative colleagues said … ‘If you structure it properly, we have a heart. We have a heart for kids,'” Dunnigan said. “Frankly, I was surprised at some of them. But I give them credit because they were willing to listen to what the bill was actually trying to accomplish.”

Proponents of the policies argue that while undocumented coverage expansions require significant ongoing funding, the dollars represent only a small part of their state’s budget and will save money in the long run by encouraging people to receive preventive care and keep people out of emergency rooms, reducing uncompensated care costs. They also argue the move will bring equity to mixed-status families where some people are eligible for health care and others are not, and that immigrants pay taxes that go to fund these types of programs.

But some lawmakers — in addition to having concerns about the cost — fear that opening up coverage will lead to an influx of undocumented immigrants from surrounding states, though several studies examining the so-called “magnet effect” of health care benefits have found that people move primarily for better housing, family reasons and jobs. They also argue that expanding the program too quickly could burden the state’s health care infrastructure and create problems that could leave people without coverage.

In Maryland, Democratic leadership scuttled a bill this year that would have allowed undocumented immigrants to purchase plans through the state’s health insurance exchange, saying the issue needed more study.

“What you have is a group of people who have identified a solution to a part of the problem and, I think because of their passion and their desire to see the health care needs met, they don’t necessarily understand why we want to look at all of the options available to us,” Maryland Senate Finance Committee Chair Melony Griffith, a Democrat, told reporters last month. “We want to make sure we’re meeting the needs of the most vulnerable, and getting the most out of the investments the state makes.”