Plot twist arises in Medicaid discussion

Poor Americans stand to lose out

— An unintended wrinkle in the federal Patient Protection and Affordable Care Act gives about 87,000 foreigners residing legally in Arkansas the right to federal dollars to buy health coverage on the state’s insurance exchange.

Meanwhile, some of the poorest of the state’s citizens would be left without insurance if the state doesn’t expand Medicaid.

“This is just another piece of evidence that things are continuing to come out in the open almost on a weekly basis for policymakers to digest and make decisions on,” said state House Speaker Davy Carter, R-Cabot. “It only supports what I’ve been saying and [Senate President Pro Tempore Michael] Lamoureux and others: We’re not going to rush this, to make decisions on this thing.”

But many Democrats have a different take. The latest twist from the federal healthcare law presents them with potential political ammunition.

“We keep finding arguments to support expansion,” said House Minority Leader Greg Leding of Fayetteville.

On Thursday, supporters and opponents of adding 250,000 Arkansans to the $5 billion Medicaid program digested the news. Many lawmakers declined to comment until they could get a better grasp on the newest revelation in President Barack Obama’s health-care overhaul.

The Associated Press first reported the legal anomalyas part of the reasoning behind Arizona Republican Gov. Jan Brewer’s decision to support expansion in her state. She had previously opposed expansion. Arizona has a large population of foreigners living legally in the state.

Under the new health-care law, people living legally in Arkansas who have household incomes below the poverty line and who have to wait five years before qualifying for Medicaid have the right to federal subsidies on the state’s insurance exchanges.

Those exchange subsidies pertain only to native-born citizens earning more than the poverty level, or $11,170 for an individual.

Congressional lawmakers included that provision under the assumption that Medicaid expansion would be automatic. But last year, the U.S. Supreme Court gave states the choice of whether to participate in Medicaid expansion, affording an unforeseen edge to legal foreigners in states that don’t expand Medicaid.

If Arkansas lawmakers choose not to expand Medicaid, residents making between 17 percent and 100 percent of the poverty level would be ineligible for any coverage. For individuals that translates to annual earnings between $4,244 and $11,170.

Recent data from the Winthrop Rockefeller Foundation indicate about 87,000 foreigners live legally in Arkansas, many of whom already have health coverage.

Democrats largely support expanding Medicaid up to 138 percent of the poverty level, or $15,415 a year for an individual, as allowed by the health-care law.

The federal government would pick up the entire cost of expansion until 2017. By 2020, the state would need to pay 10 percent of the cost.

Republicans worry that supporters’ estimates of hundreds of millions of dollars benefiting the state won’t materialize. Instead, they fear an added financial burden in the coming decade.

But tossing the politically combustible issue of immigration into an already heated debate is likely to add nuance to the national debate, many observers said Thursday.

In Arkansas, most expansion supporters were circumspect about any possible political advantage.

“The Supreme Court ruling tears the fabric of congressional intent. We at the state level have to try to sew it back together,” said Dr. Joe Thompson, the state’ surgeon general.

But Thompson allowed that the possible favoritism toward legal foreigners under the law as it stands benefits expansion supporters.

Jay Barth, a political science professor at Hendrix College who has been active in Democratic Party politics, said Arkansas Republicans have generally been careful to make the distinction between legal foreigners and those in the country illegally, but the latest facts provide “momentum” for expansion.

“I do think opponents [of expansion] have a very clear ideological argument, but the other side is increasingly working with empirical evidence,” he said.

Blocking expansion while favoring legal foreigners “does seem contrary to some basic fairness issues,” Barth said.

Sen. Larry Teague, D-Nashville, said the news caught him “flat-footed.” He said it’s too early to tell how the law’s anomaly regarding foreigners will affect the debate in Arkansas.

“But if you’re going to give it to them, then you sure ought to give it to our people,” Teague said.

It’s “too hypothetical” to see how the issue will play out politically, said John Burris, R-Harrison, and chairman of the House Public Health, Welfare and Labor Committee. At first blush, though, he said, it just reinforces his reluctance to act quickly on any expansion.

“It’s one more example of the flaws in this legislation,” he said. “Let’s wait and see what quirk will surface next.”

Arkansas Advocates for Children and Families, which supports Medicaid expansion, said it wants legal foreigners as well as citizens to have health coverage. Offering a path to health coverage for those who are otherwise ineligible for Medicaid - at least for a significant period of time - is a good thing, said Anna Strong, the group’s health-policy director.

The state’s insurance exchange is expected to enroll about 211,000 people starting in October. Coverage begins in January 2014. Federal subsidies are available for up to 400 percent of the poverty level, or an income of $92,200 for a family of four.

Rep. Bruce Westerman, R-Hot Springs, said he is becoming frustrated with the rapid changes in the “boundaries” of the debate.

“Every day we turn a new leaf on Medicaid,” Westerman said.

Gov. Mike Beebe supports full expansion, said his spokesman Matt DeCample.

“This doesn’t change anything for us,” he said.

Front Section, Pages 1 on 01/25/2013

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