Conference Call: Is Medicaid Expansion Like “Hotel California?”

Robert Alt | President, Buckeye Institute for Public Policy Solutions

Ed Haislmaier | Senior Health Care Advisor, National Federation of Independent Business

April 4, 2014

Jonathan Ingram

Hello everyone and thank you for joining me. I’m Jonathan Ingram, the Director of Research at the Foundation for Government Accountability. FGA builds paths to better lives by equipping state leaders with proven strategies to reform their failed health and welfare programs, all across America. We do this by working with you to develop, promote and help implement these solutions in your state. I want to thank all of our policymakers in the 16 states who are participating on the call today. During the last portion of the call if you’d like to ask our guests a question just press *6 when I make the announcement and that will get you into the question queue. We’ll also be asking some of the pre-submitted questions that many of you have already sent us, through our registration page.

We’re glad today to be joined by two experts with deep experience in the Medicaid expansion issue. Heritage Foundation Senior Fellow Ed Haislmaier, and Robert Alt, the President of the Buckeye Institute.

As many of you probably know, Ed is an expert in healthcare policy at The Heritage Foundation. He’s frequently asked to help lawmakers design and draft specific reforms to the healthcare systems, and his expertise really includes healthcare tax policy, Medicare, Medicaid, pharmaceuticals and healthcare price controls.

Our other guest today, Robert, is the President of the Buckeye Institute for Public Policy Solutions. His commentary has appeared in major publications, including The Wall Street Journal, The Washington Times, The New York Post, US News and World Report, and he frequently contributes to National Review Online. He has also provided commentary on CNN, Fox News, PBS and numerous syndicated radio programs.

I want to thank you both for joining me today.

Now, we all know that when the Supreme Court ruled on ObamaCare last year, one of the things that they did was to make the decision to expand Medicaid to this new class of able-bodied, childless adults optional. The federal government promises to pay 100 percent of these costs initially, and then ratchet that down to 90 percent over time. One issue that comes up in state after state is the very real concern that the federal government is really unlikely to keep that funding promise. So we’ve seen time after time where the federal government promises states that it will fund something, whether that’s special education or Build America Bonds, and then that funding never really materializes as promised. So some states, eager to really implement this ObamaCare-Medicaid expansion, but wary of the federal government breaking its promise, have tried to enter what they consider triggers or circuit breakers into their expansion plans—where the expansion would be rolled back if the federal government ever broke its funding promise. But there’s a large, looming question over whether a state can legally do that; whether they can legally exit the ObamaCare Medicaid expansion once they’ve entered into it. That’s really what we’re going to talk about today.

Robert, let’s start with you. Can you walk us through why states may have trouble legally leaving the Medicaid expansion once they accept it?

Robert Alt

Sure. I thank you once again for having me on, and I’d like to thank FGA for sponsoring this important phone call.

I think there’s a lot of misconceptions about what it is that the Supreme Court’s decision did. We remember the Medicaid expansion part of that decision was sort of the silver lining to the cloud with regard the challenge to ObamaCare, in that the Court looked at the claim of 26 states. Two other states had filed claims separately, so all told, 28 states that had claimed that modification of the Medicaid program, effectuated by ObamaCare, fundamentally transformed the program in such a way that the states could not have foreseen that when they agreed to participate in the program.

They then looked at the additional burdens that would be placed upon the states and the potential that they would lose the first dollar of Medicaid funding. Keep in mind that Medicaid funding accounts often times for as much as 1/3 of state budgets. The threat that they might lose the first dollar of Medicaid funding for existing Medicaid recipients, they argued, was unduly coercive. The Supreme Court agreed. They fundamentally found that it was unforeseeable, the transformation of the program, and that forcing the states to contemplate losing a third of their budget was the functional equivalent of asking them to negotiate with a gun to their head.

So the Court essentially rewrote the statute making it voluntary as to whether or not the states should participate in Medicaid expansion. But there’s been a number of states and individuals who have made the assumption that once they made it voluntary or optional to participate in the program, that that voluntary option also exists with regard to exiting the program. There’s simply no support for that in the decision.

Indeed, the Court made clear that once a state chooses to participate in the program, the federal law operates as normal. With regard to that, the federal law states that the individuals in the expansion population, those people who would fall between 0 and 138 percent of the federal poverty line who wouldn’t otherwise have been covered by Medicaid, those individuals become part of the mandatory population. As such, the Secretary of Health and Human Services has at her discretion the ability to go ahead and withhold the first dollar of Medicaid funding, even for the pre-expansion population, if a state makes a decision to withhold benefits for that mandatory population.

All that is to say, it creates the Hotel California. You can check in. You can opt in to Medicaid expansion, but if you attempt to opt out, it’s solely at the discretion of the Secretary of Health and Human Services as to whether or not you would be permitted to opt back out. She holds in her hand the sword of the entirety of a state’s Medicaid funding to attempt to induce the state to continue to participate. I think it’s also very important to keep in mind that it is quite foreseeable that there would be potential changes to Medicaid funding in the future.

Before the Supreme Court issued its decision, the Obama Administration had put forward a proposed budget in which they suggested modifying the match rates, the generous, 100 percent match for the first few years followed by a phase down to 90 percent, suggesting that perhaps they would use a blended rate. For my state, Ohio, that blended rate would have cost roughly $2 billion more just for what they considered to be a minor tweak and adjustment in the matched spending. That said, after the Supreme Court issued its decision making initial participation voluntary, the Administration backed down on its request to blend the rate, stating that they were going to go ahead with the more generous match rate, tellingly, in order to induce the states to participate in the program. That is, to get them to check into the Hotel California. The idea here is very clearly to make sure that the states participate on the front end. Once they’re in, there’s quite simply no promises that they won’t change the rates later.

Jonathan Ingram

Thank you, Robert, for really summing that up nicely. I think what I heard you say is that when the Supreme Court ruled on the Medicaid expansion, it said that states really couldn’t foresee that Congress would completely change the program to make expansion to this new group of able-bodied, childless adults, but the states could foresee that the federal government might break this funding promise. Did the Court address whether or not this is a foreseeable risk in their opinion?

Robert Alt

It did indeed. The Court emphasized that changes made by ObamaCare were unforeseeable to the states and that it would, therefore, be problematic to hold the states’ to conditions that they could not have anticipated changing. Here the prospect of the government changing the match rate is so foreseeable that 7 of the Justices joined opinions acknowledging the real possibility that the federal rates could change, leaving a significant burden in the states.

In responding to the assertions of relative, modest cost increases for the states, 3 Justices cautioned that such a claim, “Not only ignores increased administrative expenses, but also assumes that the federal government will continue to fund the expansion at current statutorily specified levels. It is not unheard of, however, for the federal government to increase requirements in such a manner as to impose unfunded mandates on the state.” This concern was echoed in an opinion joined by 4 Justices, which emphasized that, “Costs may increase in the future because of the very real possibility that the federal government will change funding terms and reduce the percentage of funds it will cover. This will leave the state to bear an increasingly large percentage of the bill.”

Accordingly, should the states march back in to court claiming that this was somehow unforeseeable? Far from saying that the change was unforeseeable, the Court is likely to say, “We warned you.”

Jonathan Ingram

That really seems like the very real possibility that the Court would simply say, “Look. We told you that this rate could be adjusted, and you knowingly opted into the Medicaid expansion anyway.”

Ed, let’s bring you in here. Beyond what the Supreme Court itself foresaw, are there other reasons to think that the federal government might break its promise? I know that Robert just hinted that the federal government has proposed a few different cost shift ideas for the Medicaid program. Can you talk to us a little bit more about that?

Ed Haislmaier

There is clearly a substantial fiscal issue here for the federal government. That is we now have a situation where roughly half the states are expanding Medicaid and the other half aren’t. But this match is well above everybody’s standard match rates. Even the poorest states are at about a 75 percent match rate. If you did nothing else, if Congress simply scaled the match rate back to the normal match rates for every other population, there would be tens and tens of billions of dollars of savings to the federal government there.

If you look at the costs that this and other entitlements were imposing on the federal budget, it certainly is something that ought to be on the table, I would think, if anybody’s at all serious about controlling federal spending.

Jonathan Ingram

Thank you, Ed. So I think what you’re saying that it’s clear that states should be worried that this could happen. I think one of the trustees that President Obama himself appointed to the Medicare program actually said that it’s a near certainty that federal funding promises are going to be broken.

Robert, this might be more for you, but hasn’t the federal government sort of reassured states that they could leave the expansion whenever they want? I remember reading a few letters from the Obama Administration telling state leaders essentially, “Don’t worry. You can leave anytime you want.” Can you walk us through why those letters aren’t really meaningful protection for states?

Robert Alt

Once again, you could trust everything the Administration says on this. If you like your plan you’ll be able to keep it. If you want to opt out you’ll be able to. The second providence is probably nearly as good as the first. The reason here is, first of all, they argue…I’ve heard several states. It was in argued in Ohio when Medicaid was considered saying, “Look!” Secretary Sebelius went up and testified before Congress and she made an oral statement that she wouldn’t go ahead and withhold funding if a state wanted to back out. There was a Q & A sheet put out by the Centers for Medicaid and Medicare services which stated that the states would be able to opt out. This wasn’t a regulation. It didn’t go through rule making. This isn’t law. This was just a Q & A statement, and the suggestion that somehow this would bind the federal government. The answer plainly is no as a legal matter.

The Courts have drawn up a doctrine; the idea was to protect the states in these situations. Remember what we’re dealing with here. The federal government has certain limitations on what it can force the state to do. If it tries to do too much. Some of you may remember there was a case involving background checks in which they ordered sheriffs to perform the background checks. The states sued and won because that commandeering state officers. So they can’t force them to do things directly, but they can offer funds, essentially, to bribe the states to do what they want them to do. What we’ve got with the Medicaid system issue got certain inducements.

Often times there’s a number of strings attached, so the courts in interpreting these treat it like a contract. They treat the federal statute as a contract between the federal government and the states essentially saying, “Look, the states have to be given sufficient notice of what’s going on in the statute. We’re going to look to that. We’re going to look to the federal law to see what’s required of the states in exchange for the money.”
Insofar as the Secretary’s making these statements—which are not in the statute, which are not in rules, which are not binding upon the federal government—if they choose later on to say “No, we’re going to exercise our rights under the statute to withhold the first dollar of federal money” the courts are very likely to permit that, and indeed that is probably the most likely outcome based upon that alone. The evidence from these Q & A documents is not going to be binding on the courts.

Additionally, keep in mind, even if they were statements that would have some legal effect, and I don’t think they are, they would only potentially bind the current Administration or the current holder of the office of the Secretary of Health and Human Services. At any point when a new Secretary comes in, she can go ahead and reverse course, reverse her decision on that. There’s nothing to bind future Secretaries to that. They could go ahead and say, “No. Actually you can’t get out and if you do, we’re going to withhold the first dollar of funding.” There would be nothing to restrict them from doing that.

 

Ed Haislmaier

And I’d like to get Robert’s take on this because, of course, he’s the real legal expert here, not me. Beyond what Robert just said, the point that I have made, and Robert, please correct me if I’m wrong, but you look at this and you see what the Court did not strike the statute, and the Court did not amend the statute. What that means then is the statute as enacted is part of the Code, and it’s in, this expansion is in the mandatory section of the Medicaid statute, not in the optional section. I think it’s very significant, as Robert pointed out, that they, after 2 years after the ruling almost, haven’t actually issued even a proposed regulation, and that all they’ve done in terms of promising that the states can get out is this Frequently Asked Questions Q & A. I think possibly the reason is because they recognize there’s no statutory basis for saying that.

The larger point that I’d like to get at is this has been discussed in terms of the federal government’s relation with the states. But it seems to me that in this state of affairs, if a state that has adopted the expansion were to, for whatever reason, try to reverse itself and take HHS’s Q & A at its word and reverse the expansion, and thus some people who had gained coverage on the expansion would lose coverage, any of those affected individuals, regardless of whether—the HHS can say, “Yeah, yeah, yeah. That’s fine. You can leave.”—any one of those affected individuals, I would presume, would have standing to go to the Court and say clearly they’ve been harmed, and that the Court should enforce the statute as written, which doesn’t give either the state or HHS the ability to do that.

Robert Alt

They would have standing on this, Robert. First of all then, with the point you made with regard to the mandatory population. I think that really is the key here. There’s nothing in what the Supreme Court’s decision did which modified the statute, which makes the individuals in the expansion population mandatory. Once again, federal law is very clear. If you are a state and you fail to provide the coverage requisite for the mandatory population, the federal government in the form of the Secretary has a big stick, and that big stick is the ability to withhold first dollar of Medicaid funding. There’s nothing which eliminates that.

The Administration has made non-binding statements that, “We won’t do that.” They’ve also said that, “If you like your coverage you can keep it.” I don’t know that I would make a multi-billion dollar bet if I was a state on either of those propositions.

As to the ability of an individual to sue, who lost coverage. Presumably they would have standing to do so. If the federal government went ahead and let someone out of the program, the courts might go ahead and let that go simply because the discretion is invested in the Secretary as to the penalty to apply. The question would be, at least with regard to the decision, whether or not to withhold first dollar of Medicaid funding. They probably wouldn’t impact that question. The Court would probably defer to the Secretary’s discretion on that. As to whether or not they’re required to cover, that’s actually another interesting question that Ed raises. On that, I don’t know how the courts would treat that as to remedy. Again, there’s quite simply nothing in the law which would suggest that this would be optional population once you’ve opted in. So it certainly is possible that the Court would look to that to see whether an appropriate remedy would be to require coverage.

Ed Haislmaier

At which point then the Court could require that the individual be reinstated, and leave it up to the state and the Secretary as to how much the federal government will pay for the cost of that. Would that be the implication there?

Robert Alt

Presumably. I haven’t thought about the specifics on how it would parse that out.

Ed Haislmaier

It does seem, at least to me, to be too hard to envision a court coming to that conclusion because clearly the individual’s been harmed, and the individual doesn’t have an interest as to how much it’s paid by the federal and the state government, but they clearly do have an interest in being covered. Then, of course, if you get one of those then everybody else who has a similar situation would have reason to go in and sue.

Jonathan Ingram

Right. And thank you both for bringing that up because I think it really illustrates the fact that even if the Obama Administration, or maybe the next Administration, even if they would want to let states back out of this optional Medicaid expansion, it really isn’t a sure thing. You’re opening yourself up to all kinds of legal headaches even if both parties agree that that’s what should happen.

I want to thank both, Ed and Robert, again for taking the time to really explain the nuts and bolts of this to us. I know we probably have a lot of questions so I want to open it up to Q & A for the time that we have left. Remember, if you want to get into the question queue, just press *6, and we’ll try to get to as many as possible. We do have a few pre-submitted questions from listeners so while people are getting themselves into the queue, I’m going to go ahead and start with some of those.

Ed, this is probably best answered by you. We have a question from Utah. All of this assumes, even if you’re legally able to reverse course on the Medicaid expansion, that there will be a political will to actually do that. Can you talk to us a little bit about the political difficulty in rolling back an entitlement once it has taken root?

Ed Haislmaier

You mean at the state level? At the state level, of course, it would be politically very difficult. I could envision a compromise at the federal level. Let’s talk about that very briefly. I can certainly envision the situation where for budgetary reasons you say, “Well we want to scale back to match rate.” Then what you do as part of doing that is you actually transfer the provision in statute from the mandatory side to the discretionary side, and you leave the states in the situation where you say, “Okay. This was all set up as mandatory with you getting all this extra money. We don’t have the money, so what we’re going to do is we’re going to take away the extra money. You can do this at normal match rate, but we’re going to move it over to the discretionary side of the statute, so it’s up to you to decide whether you want to do it.” In which case I would think you would see a very different picture. Some of the more liberal states might very well continue on. Prior to ObamaCare, New York was putting everybody it could find on Medicaid, it looked like anyway. That I could see conceivably happening at the federal level and the right set of circumstances.

At the state level, to back out would be very difficult because you would be throwing people off the rolls. Aside from the legal challenge we just discussed, that’s politically very difficult. We have had experience with that in some states. The most significant one being Tennessee with the failure of an attempt to expand the coverage like this called TennCare. I remember post-that, meeting with folks in Tennessee and coming away with the impression that if there was anything bipartisan in Tennessee government, it was that they didn’t want to ever do that again. I think this is the reason Arizona, for example. I was surprised that Arizona, the legislature was able to hold out as long as it did because Arizona was one of the states that didn’t expand the Medicaid, as you guys have written about and, in theory, could have kept doing this under a waiver, but HHS wasn’t going to give them the waiver to force them to accept the expansion. So if they didn’t accept the expansion, they’d have to throw people off the rolls. Unlike other states that were simply debating whether to add people.

Jonathan Ingram

Thank you, Ed. I know that in my own home state of Illinois, our disgraced former governor who’s now in federal prison, unilaterally expanded Medicaid without legislative approval. It took 5 years, multiple court cases and court orders, with injunctive relief and a $2 billion Medicaid deficit before they were actually able to roll back the illegal expansion of Medicaid. I think that I also see this huge political liability in states that expand and then say, “Oh we’ll want 3 years. Once we get these tens of thousands, hundreds of thousands, millions of people enrolled, we’ll just opt back out.”

Ed Haislmaier

Could I make one other point here, Jonathan?

Jonathan Ingram

Absolutely.

Ed Haislmaier

There’s an equity issue here as well, okay? I think this gets lost in it. What this does is it sets up a system that says to a state, “If you pay for disadvantaged individuals. Poor children. People who have traditionally been on Medicaid. If you pay for people who are disadvantaged. They’re poor kids, they’re disabled, they’re poor pregnant women, they’re poor elderly. We will give you less reimbursement than if you pay for putting healthy, able-bodied young adults with no dependents on the program.” One can make an argument. Let’s just take, since you used Illinois which is a 50/50 state. Why should the federal government pay Illinois 50 cents for every poor kid in the projects of Chicago? Pay 50 cents of the cost of their medical care, but pay 100 cents of the cost of the medical care for the nominally poor graduate student at the University of Chicago who comes from a middle class background?

Robert Alt

If I could jump in as well in terms of what Jonathan said. I think the politics on this ends up being another big issue to think about with regard to the so-called Circuit Breakers theory. I’ve had numerous conversations with state legislators in which they said, “Look. We understand that the federal government is trillions of dollars underwater and adding to the debt every day, and that the burden that it’s taking on with regard to Medicaid is unsustainable. They’ve offered these generous match rates up front but that’s just not going to be able continue. But we want the gravy while we can get it. We’ll take it. Then we’ll go ahead and put in this trigger, so the moment that they go ahead and drop it. I’ve seen some of them written even where they’ve dropped the match percent by even 1 percent. Well then we’re out. We’re out of Medicaid.

Well one that presumes that legally you can do that, but let’s just indulge the presumption for a moment. Let’s pretend that Secretary Sebelius says, “Okay. It’s still in,” and she says, “Yeah. Fine. Go ahead.” The presumption here is somehow that there’s no political conflict for one who’s associated with that. That you’re going to by operational law, without a legislator acting, you’re going to knock, in some states, hundreds of thousands of people off the Medicaid rolls, and there won’t be calls to go ahead and reinsert it. The fact of the matter is the budgetary blood would be on a legislator’s hands up front. If you know that there’s a high probability that the match rate is going to change, that the states are going to be on the hook for additional dollars. It’s not like you’re going to simply be able to drop all these individuals and not have screams, hollers, pitchforks and torches, claiming that you’re now taking away a benefit. There’s going to be political consequences. So if we’re relying on the thinking of the Supreme Court, this is all foreseeable enough that a lot of the legislators even anticipate it. That’s why they’re talking about the Circuit Breakers because they know this isn’t sustainable.

Jonathan Ingram

Thank you, Robert and Ed both for those deep insights. I think we have a call from Idaho, so if you want to go ahead with your question? Idaho?

Cheryl Knoxville

Yes. This is Cheryl Knoxville from Idaho and I need to go a little bit more basic. If I understood you correctly, you say if you failed on mandatory expansion then you could withhold one dollar of funding of Medicaid from the federal government, or the federal government will withhold that. I’m not sure I heard that right. If it was mandatory expansion. And then also, I want to know, how do you withhold one dollar of funding? One dollar of what? Per person? I mean, what do you mean by that?

Robert Alt

Sorry. It sounds like I may have been unclear. What I was saying is first dollar. Why I use the term “first dollar” is this. So you’ve got your Medicaid program in your state already. If you haven’t engaged in the expansion, it covers at least the mandatory populations. The aged, blind, disabled, pregnant women and families with dependent children up to certain poverty thresholds, and you get a big chunk of dollars. In many states, that’s nearly a third of their total state budget is matching funds to help cover those populations. Now you have the option of expanding it. To expand that you get more dollars to cover people from 0 to 138 percent of the federal poverty level who aren’t in those previous groups. That goes to the equity issue that Ed was talking about. If you’re in one of those previous groups and you’re in 0 to 138, you get the lower match rate. But if you’re an able-bodied male who’s capable of working, but you’re 0 to 138, the state gets 100 percent. It doesn’t really make a whole lot of sense but that’s the way it works.

The question is, what happened? First of all, how do we treat those individuals? We treat them as a mandatory population, and that’s important because there are certain optional populations that the state can cover. They can go ahead and cover more people, so long as it’s authorized by the statute. Then they can do some of the things the states are claiming they might be able to do here. They can go ahead and sign up, and if it doesn’t work, they can go ahead and drop out of the program. There’s no penalty to them for doing so. But if it’s a mandatory population. If it’s something where to participate in the program, you have to provide coverage? And that’s what happens when you accept the expansion. That 0 to 138 becomes a mandatory population. At that point, federal law gives the Secretary of Health and Human Services a big stick. When I say first dollar, I mean the existing funds that you were already getting. They’re allowed to take away all of your Medicaid money. They can say, “If you don’t provide coverage for the expansion population, we’re taking it all away.” Often times a third of states’ budgets. So it’s not one dollar. Perhaps it was unclear. I was talking about first dollar. They can go ahead and not just claw back the new dollars that they were giving for the Medicaid expansion, but every dollar that they’ve given for Medicaid.

Jonathan Ingram

Thank you for that explanation, Robert. So our listeners are all clear, what you’re saying is that this population that becomes a mandatory population once the state opts in. As long as the state has not opted in, they don’t become a mandatory population for them to cover.

Robert Alt

That’s correct.

Ed Haislmaier

Could I, Jonathan, be very precise on that?

Jonathan Ingram

Absolutely.

Ed Haislmaier

Okay, the way the Medicaid statute works, as Robert said, is to get any money, you must do the following. There’s a section in there. I can give you the citation. You must do the following. It’s a very long section. You must cover these people, you must cover these services, etcetera, etcetera. What ObamaCare did is to add at the end another subsection with this expansion population group. What the Court did was to effectively not change that, but effectively put a sort of invisible asterisk next to it saying, “Well, it’s up to the State to have to first decide that they want to accept this being added.” That’s what we’re talking about here. Now, there are other things in the statute where it’s optional for the State. So, for example, I’ll use the neighbor Wyoming, which as far as I know, is the only state that sticks to the bare minimum required in eligibility. So the bare minimum required is 138 percent of the poverty for children, for example. Under the optional provision, the state could go higher. They could go to 150, as many states have done. Or higher. But they stick to the minimum. If they tried to lower it. Say Wyoming said, “Well we don’t want to pay for the kids above 100 percent of poverty.” Then the federal government could say, “No, no, no. It’s mandatory for you to get any money for any of this stuff. For the old folks in the nursing home, for any of this stuff, you must go at least to 138.” That’s what Robert’s talking about.

Jonathan Ingram

Excellent, excellent. We have one more pre-submitted question. Robert, maybe you could take this one. The average citizen’s attention span is probably around 30 seconds. Can you just sort of give us the 30-second elevator pitch for this Hotel California argument?

Robert Alt

Sure. The idea here is you can opt in but you can’t opt out. The Supreme Court’s decision made it optional for states whether they want to actually participate in the program, but once you make that choice, there’s no turning back. The law doesn’t give you the option to get out, and it gives the Secretary the discretion to issue the financially-devastating decision to take away all Medicaid funding from the states. That’s just far too big a gamble.

Jonathan Ingram

Thank you. We’re about out of time so I want to thank everyone again for joining us, and especially thank our 2 distinguished guests for taking the time to talk about this very important issue. Ed, do you have any final closing thoughts for us?

Ed Haislmaier

I think we’ve covered it pretty well. Robert and I are happy to help. Again, please talk to Robert on these legal aspects. He’s the expert there. As many of you know I’ve been working with states on some of the more economic and social reasons why not to do it, involving why it’s just bad policy irrespective of the legal arguments. So, of course I’ll be happy to help there.

Jonathan Ingram

Thank you, Ed. And Robert, any closing thoughts?

Robert Alt

There’s one thing we didn’t talk about, and I just wanted to add this as a footnote. I think there’s a lot of talk about states pursuing the so-called Arkansas Plan. Ed talked about Tennessee. I know Tennessee has rejected Medicaid expansion so far, but there’s rumblings about the Arkansas Plan. There’s rumblings about the Arkansas Plan in other states. It’s useful to remember that the so-called Arkansas Plan begins with a state opting in to Medicaid expansion, and then they converted to a premium support model. All that is to say, everything we’ve said today potentially applies to any state that adopts the Arkansas model as well, because you have to opt in to Medicaid participation and the match rates in order to go ahead and do the conversion to the premium support model.

I think that’s useful for folks to consider because often times I think there’s an attempt to confuse individuals to try and use that to say, “No, no, no, no, no. This isn’t Medicaid,” when, in fact, it is Medicaid expansion. It’s just Medicaid expansion with another layer added on top.

Otherwise, to wrap up, I think I’d just go back to the gamble theme. Look. The people who are telling you you can go ahead and get out, they don’t have any legal support for that. They can’t point to anything legally binding that actually says, “You can get out once you get in.” They’re making an assumption based upon nothing more than naked statements made by an administration that, quite frankly, looked at the American people and … I don’t know that there’s any way to get around the fact that they lied to them. Time and time again about the fact that you could keep your plan. Even though they knew. Even though it was the intended consequence of the policy to go ahead and throw millions of people off plans that they liked. For the states, they’re making a multi-billion dollar gamble based upon a lack of legal support, and based upon just simple naked promises of a current administration which won’t be binding on the next, that’s foolhardy at best.

Jonathan Ingram

Thank you both for those final closing thoughts. If anyone wants to learn more about the private option, the Arkansas model of expanding Medicaid, we, of course, have several things on our own website at UncoverObamaCare.com. Thank you both again for presenting this useful information. Thanks to everyone for joining us today. As a reminder, we will have a transcript of today’s call posted on our website UncoverObamaCare.com where you can access additional research and resources on both ObamaCare’s exchanges and on the Medicaid expansion. Thank you all again and we will talk to you soon. Have a great day.