1. Comments on the Affordable Care Act (ACA) and Medicaid in Alaska Lawrence D. Weiss PhD, MS February 2013

2. Medicaid Nationally created by Congress in 1965 public health insurance program for low- income families and individuals covers about 63 million US residents, about 20% of the total population Jointly funded by feds and states

3. Medicaid in Alaska covers a broad range of services such as inpatient and outpatient hospital care home and community-based long-term care prescription drugs, dental, mental health, drug abuse expanded preventive services for children

4. Alaska Enrollees I 137,000 enrollees, about 19% of the total population 59% are children 34% adults (disabled; low-income parents of children on Medicaid) 7% are "aged"

5. Alaska Enrollees II infants and children: 150% FPL, up to $43,230 for a family of 4 pregnant women: 175% FPL, up to $58,435 for a family of 4 68% of Alaska Medicaid enrollees are classified as "white" half of all babies born in Alaska are born to a mother on Medicaid

6. Governor Parnell Denounces the Affordable Care Act December 24, 2009 Senates passes ACA March 21, 2010 House passes ACA March 21, 2010 Gov. Parnell announces that ACA is "public policy at its worst," and joins 19 Republican governors and governors- elect urging Congress to dump ACA and replace it with "meaningful health care reform."

7. Governor Challenges Constitutionality of ACA April 20, 2010 Gov. Parnell announces that the State of Alaska will join 20 other states to challenge the constitutionality of ACA. June 28, 2012, Supreme Court issues decision on ACA Medicaid expansion in NFIB v. Sebelius Court considers four questions...

8. Individual Mandate I Question: Is the challenge to the individual mandate barred by the Anti-Injunction Act? Supreme Court: The Anti-Injunction Act does not prevent it from determining the constitutionality of the individual mandate.

9. Individual Mandate II Question: Do the Commerce and/or Taxing Clauses of the Constitution authorize Congress to enact the individual mandate? Supreme Court: o the individual mandate is a valid exercise of Congress' power to tax o the individual mandate is not valid under the Commerce Clause and cannot be sustained under the Necessary and Proper Clause

10. Unconstitutional Coercive Condition Question: Does the ACA Medicaid expansion represent an unconstitutionally coercive condition on states' participation in the Medicaid program? Supreme Court: The Court accepted the argument from 26 State officials they were being unduly coerced into accepting the ACA's requirement to expand Medicaid.

11. Is the Entire ACA Invalid? Question: If a provision is unconstitutional, is the entire ACA invalid or can all or part of the remaining law be "severed" and remain good law? Supreme Court: "Nothing in our opinion precludes Congress from offering funds under the Affordable Care Act to expand the availability of health care, and requiring that States accepting such funds comply with the conditions on their use. What Congress is not free to do is to penalize States that choose not to participate in that new program by taking away their existing Medicaid funding." So... Undue coercion remedied and the rest of ACA stands.

12. General Implications for Medicaid I NFIB does not make the Medicaid expansion optional for states, but it does hold that the Secretary of HHS cannot terminate existing Medicaid funding for a State that does not implement the expansion. However, states that do implement the expansion must comply with all mandatory provisions of the Medicaid Act.

13. General Implications for Medicaid II The federal matching provisions for the expansion of Medicaid under ACA are not affected by the decision. NFIB does not authorize states to receive 100% to 90% federal funding for implementing less than the full Medicaid expansion (e.g. "all individuals" with incomes below 133% FPL)

14. General Implications for Medicaid III The ACA's other additional added Medicaid provisions continue in full force and effect in all states. Whether or not a state implements the Medicaid expansion, ACA's maintenance of effort (MOE) provision continues to apply.

15. General Implications for Medicaid IV States that do not implement the Medicaid expansion but continue to participate in Medicaid must comply with all other provisions of the Medicaid Act or risk losing all federal Medicaid funding.

16. A Notable Unintended Consequence The ACA provides for adults with limited incomes under 133% FPL to to be covered by the new expanded Medicaid. Low-income adults over 100% FPL may receive subsidies through the health insurance exchange to purchase health insurance. However, if a state chooses not to expand Medicaid, Low-income adults under 100% FPL will not be eligible for Medicaid nor for subsidized health insurance from the exchange.

17. Medicaid Expansion Uncertain in Alaska: Enrollments With expansion: An additional 34,760 Alaskans enrolled by 2019 (mostly adults up to 138%FPL). The number of uninsured in Alaska is cut in half. Without expansion: An additional 9,440 Alaskans enrolled by 2019 (mostly eligible under current Medicaid criteria). Combined: 44,200 additional enrollees by 2019.

18. Medicaid Expansion Uncertain in Alaska: Federal and State Funds With expansion: For every $1 the state spends, the feds return $15.50 (applies to Medicaid expansion enrollments only). Without expansion: For every $1 the state spends, the feds return $1.40. Combined: For every $1 the state spends, the feds return $7.

19. Medicaid Expansion Uncertain in Alaska: State and Fed Expenditures With expansion: 2014-2019 state spends $56 million; feds return $873 million (for expansion enrollments only). Without expansion: 2014-2019 state spends $86 million; feds return $124 million. Combined: 2014-2019 state spends $142 million; feds return $997 million.

20. Medicaid Expansion Uncertain in Alaska: Jobs With expansion: 3,700 new jobs by 2019. Without expansion: 900 new jobs by 2019. Combined: 4,600 new jobs in Alaska by 2019 (mostly in health care industry)

21. Medicaid Expansion Uncertain in Alaska: Salaries With expansion: $180 million added annually by 2019 (expansion-related only). Without expansion: $42 million added annually by 2019. Combined: $230 million added annually by 2019; cumulative total by 2019 over $1 billion.

22. Medicaid Expansion Uncertain in Alaska: Overall Economic Output With expansion: $390 million additional "total business sales" annually by 2019 (economic multiplier approximately 2.2) Without expansion: $120 million additional "total business sales" annually by 2019. Cumulative: $2.33 billion additional "total business sales" during the period 2014-2019.

23. The Big Question... What will the Governor do?

24. Lawrence D. Weiss PhD, MS ldweiss@gmail.com cell: 907.268.7072 UAA Research Professor in Public Health, Professor Emeritus (retired) founder and Executive Director of Alaska Center for Public Policy (retired) author of several books and numerous articles consultant expert witness

25. Selected Resources: National cms.gov healthcare.gov healthlaw.org National Health Law Program kff.org Kaiser Family Foundation. See topics "Health Reform" and "Medicaid/CHIP." medicaid.gov networkforphl.org Network for Public Health Law

26. Selected Resources: Local akhealthreform.org AK Health Reform commonwealthnorth.org Commonwealth North, see the "Health Care Action Coalition." dhss.alaska.gov/ahcc Alaska Health Care Commission dhss.alaska.gov Alaska Department of Health and Social Services iser.uaa.alaska.edu Institute of Social and Economic Research