West Virginia Teacher Strike

A work action has been initiated today in West Virginia, and all county schools (save one) are closed because of a really bad education bill that the Senate is trying to ram through:

A little less than a year since the start of West Virginia’s first statewide public school workers strike, leaders of the state’s three major school employee unions called Monday evening for another strike to begin, starting Tuesday, over the education overhaul bill.

All but one of West Virginia’s 54 countywide public school systems canceled school Tuesday. The outlier was Putnam County, which is among West Virginia’s wealthier counties and is near the state Capitol.

“We are taking action,” said Fred Albert, president of the West Virginia branch of the American Federation of Teachers union. “We are left no other choice, but, as of tomorrow, we are calling a statewide strike.”

He briefly referenced that he’s been told there’s support in the House of Delegates for a version of the bill that the unions oppose.

Long story short, the Republican led legislature in the state, which did not even mention “comprehensive education reform” as a legislative priority before the session started, has been up to their usual bullshit. Sen. Majority Leader Mitch Carmichael, who is as wingnutty as they come, was dead set on retribution for last year’s strike, so some heretofore relatively unknown Senator introduced a piece of ALEC written legislation with all sorts of nonsense, to include charter schools, union-busting, and a whole sort of stuff that had no chance in the House of Delegates.

The Senate, being the Senate, passed it anyway despite the fact that Republicans in the House said they hated it, the Republican governor said he would veto it as is, and virtually everyone who has ever worked in or works in education said the bill is horrible. It then went to the House of Delegates, which promptly stripped most of the crap (you can get a good look at the changes here) and passed it with a bipartisan majority. It was then sent back to the Senate.

Once back in the Senate, they promptly went back to putting all the crap back into it, including jacking up the number of charter schools, removing a provision that said legislators can not profit off charter schools, and reincluding measures to punish unions and prohibit striking. The Senate Republicans refused to allow the minority party to see the bill, and wanted to rush a vote for last night, but there was so much outrage that the votes were postponed until today. It’s a bad bill, but these are Republicans and don’t give a shit. My Senator, William Ihlenfeld (you might remember I volunteered for him and we fundraised for him) put it this way:

Last night, the comprehensive education reform bill was amended by a 18-16 vote and now will go back to the House of Delegates for consideration. Changes from the most recent House version include the increase of charter schools from 2 to 7 and putting ESAs back in after they had been removed. The amendment (130+ pages worth) was worked on all weekend by the majority without any input from the minority, and then provided to everyone 10 minutes before we were asked to vote. This is not how government is supposed to work but it is how the West Virginia Senate operates in 2019.

I voted against the Senate Amendment because of the expansion of the charter schools provision, the addition of ESAs, the uncertainty of what else was in the amendment (even the lead sponsor admitted she hadn’t read all of what was being proposed), the lack of real input from West Virginians, and the oversized influence from outside interests like ALEC and the the Koch brothers-funded Institute for Justice. We don’t need outsiders to tell us how to run our system of education in West Virginia but that’s what has happened with SB 451.

The House Version that was passed last week wasn’t perfect but it was much better than the mess of a bill that the Senate passed out originally. What the House sent back to us was a gift and Senate leadership should have accepted it and said thank you. Instead, they refused it, and added back in much of the garbage that the House had removed.

I’m hearing that the House of Delegates may have the votes to pass the Senate version but that the margin is very slim. I encourage you to contact your representatives to let them know how you feel. Make sure that your voice is heard as you may be able to persuade those who are on the fence.

If you are an educator and will be in Charleston today, please stop by my office in W-229 and say hello. If you need a place to put your jacket, charge your cell phone, or fuel up (I have lots of candy), my office is your office. I hope to see many of you today at the Capitol, and despite what the Putnam superintendent did, we are still #55Strong.

We’ll see what happens next. Now we have to watch as the legislature tries to ram through campus carry over the objection of every educator and educational establishment in the state.

Good news for Texas Medicaid

Texas is thinking about doing something very smart.  They want to expand the current mandatory categorical eligibility for Medicaid for pregnant women that currently expires at sixty days after birth to a full year of eligibility after birth.

The Dallas Morning News has details:

To combat maternal mortality and morbidity, several Democrats and at least one Republican have proposed extending Medicaid coverage to one year after a woman gives birth or has an involuntary miscarriage.

“This is a really important bill because there is a gap in treatment, and this will ensure Texas women will continue to receive Medicaid coverage for 12 months,” said Rep. Shawn Thierry, D-Houston, who filed a bill to extend coverage. “I believe that this will reduce the maternal deaths.”

In 2016, Texas gained national attention for having the “highest maternal mortality rate in the developed world,” based on data from 2012 that was published in a study. Last year, the state found that inaccurate reporting inflated the data, but officials have continued efforts to lower the numbers.

Medicaid requires states to cover income qualified pregnant women for the pre-natal period and for sixty days after birth.  The theory is that work is difficult in this time period, the baby needs intensive parental attention and good healthcare for the mom will lead to better health and development outcomes for the baby.  Income restrictions are much higher for this adult population than many other adult eligible populations.  In Texas, a woman can earn roughly $32,000/year to qualify as a pregnant woman with a single child.  After sixty days, the current income cut-off for the same family to get the mom Medicaid qualified is $2,400 per year.   Texas transitions women to a limited benefit plan if they don’t qualify for low income Medicaid sixty days after birth.

That is a huge cliff. And many women will fall off that cliff. If they are earning over 100% FPL, they are eligible for a subsidized exchange plan. If they earn under 100% FPL (~$16,480 for a family of two) they get no exchange subsidies and most likely earn too much to qualify for low income Medicaid. A lot of people fall off the cliff.

New Jersey is considering a similar change to their Medicaid program. They are a Medicaid expansion state but Medicaid expansion cuts off at 138% FPL while low income pregnant woman eligibility cuts off significantly higher. It would promote continuity of care.

This is interesting and potentially good news from Texas and New Jersey.

Spending more to cover less — fiscal responsibility in Utah edition

Utah’s governor just signed into law a limited Medicaid expansion that the legislature passed over the past ten days. The new law overturns the full expansion that voters approved in November.


Utah’s voter-approved Medicaid expansion initiative was replaced Monday with a program that is more restrictive, initially more costly, and contingent on a series of uncertain federal concessions.

Utah lawmakers and Gov. Gary Herbert, though, say the bill is more economically sound over the long term.

Senators voted 22-7 to adopt the House version of SB96, which launches a partial medicaid expansion April 1 and would revert to full expansion only in the event that federal administrators reject multiple requests for Affordable Care Act waivers.

Over the short term, this bill will cost Utah more money.  The Affordable Care Act provides for a 90% long term federal match (and a 93% match in 2019) for full expansion of Medicaid to 138% of the Federal Poverty Level (FPL).  Partial expansions to 100% FPL don’t qualify for that full match.  Instead, the feds will pay the standard match, which in the case of Utah is 68% of the incremental costs.  Utah will be on the hook for 32% of the costs of a smaller population.

Utah thinks that they will get a waiver from the Center for Medicare and Medicaid Services (CMS).  This waiver will contain the now “typical” work requirements but also two new major elements:  A cost control cap with an associated enrollment cap and the full ACA enhanced matching rate.  Those two elements have never been approved before.

Adrianna McIntyre, Allen Joseph and Nicholas Bagley reviewed partial expansion logic in the New England Journal of Medicine in the summer of 2017.  They noted the financing mechanics and incentives for states to avoid the 100-138% FPL population in the Medicaid pool:


Why were states interested in these partial expansions? Starting in 2020, states are responsible for covering 10% of the costs associated with the Medicaid expansion. Because of a drafting mistake, however, the ACA says that the 100-to-138 population can receive subsidies to purchase a private health plan on the exchanges — but only if they are ineligible for Medicaid.3 For those people, the federal government bears the entire cost of subsidizing private coverage, with no contribution from the states. As a result, the states save money for every beneficiary whom they can move from Medicaid into their exchanges…

On the practical side, many states would probably demand similar waivers. Unlike the federal government, states are obliged under their constitutions to balance their budgets every year. They will welcome the chance to reduce Medicaid obligations and alleviate budgetary strain. Hospitals, physicians, and other providers will probably support partial expansion because private insurers pay them better than Medicaid does.

Partial expansion would not just shift a financial burden to the federal government; it could also increase the size of that burden. Arkansas’s decision to enroll beneficiaries in private plans increased expansion costs by 24%; in other states, the disparity between Medicaid and private costs could be much higher. Between premium subsidies and supplemental cost-sharing reductions, the federal government will probably shoulder more than 90% of the price tag for this costlier coverage, with beneficiaries picking up the difference….

CMS has denied a partial expansion for Arkansas.  CMS has also never offered to pay the enhanced ACA rate for BadgerCare in Wisconsin.  BadgerCare is a waiver program that extends Medicaid to Wisconsin residents who earn up  to 100% FPL.

Utah’s new law is betting that CMS will establish precedent that transfers large costs back to the federal government and dramatically increase the likelihood that several more non-Expansion states will expand.  The first assumption is a hard assumption under any administration.  The second assumption is a difficult assumption under this administration.  If the enhanced match rate is not authorized, Utah will default back to a full expansion after a little more than a year.

UPDATE 1: Adrianna McIntyre and I have a new piece at Health Affairs Blog that look into the policy implications.  We build off of her framework from NEJM and incorporate silver loading effects.


States, policy innovation and proofs of concept

Many states are proposing a series of experiments with their health care markets that are aimed at expanding coverage, increasing actuarial value, and limiting provider payments.

Medicaid Buy-ins

  • New Mexico
  • Nevada

Public Options with Medicare-like rates

State based mandates

  • New Jersey
  • Massachusetts
  • Vermont
  • California
  • Maryland

Downpayment Plans

  • Maryland

Expanded Subsidies

  • California


I agree completely with Adrianna.

These states will provide evidence of what can work, what trade-offs are real versus illusive, what some of the unexpected interactions may be, and the challenges of figuring out how to cover more people for roughly the same cost.  The liberal  experience in health policy from 1994-2007 was a long consensus building session as to what could be done within self-identified political constraints and limitations.  Massachusetts with a large Democratic super-majority in both chambers of the legislature was the proof of concept of the three legged stool approach.  The three legged stool was a combination of guaranteed issued/community rated insurance that was backed by significant low-income subsidies to make the insurance affordable and a mandate to get and keep healthy people in the risk pool.  Medicaid was the base of the coverage expansion with the private market taking more of the load up the income scale.  The three major Democratic primary contenders in 2007 all bought into variants of this plan and the major veto players in the Democratic Senate caucus were also on board.

I think that the states are limited in what evidence they can provide on a pure single payer system.  They don’t have the counter-cyclical fiscal capacity nor the expectation of seeing waivers approved to unlock significant federal fund flows for that project.  However they can test the impact of expanding subsidies, offering government price leveraged plans and using Medicaid further up the income scale.  These are all needed and worthwhile policy experiments.


Medicaid buy-in support

Friend of the blog, Emma Sandoe and other researchers in Boston, ran a poll on Medicare for All and Medicaid Buy-in programs.

The results are interesting on several metrics:

Medicare for All has about 36% support and 38% opposition. That is a steep hill to climb to build a majority coalition.

Medicaid Buy-in has a majority in at least tepid support and very little passionate opposition.

This is interesting on several levels.

The first is that Medicaid’s branding seems to be stronger than Medicare’s branding.

Secondly, Medicaid buy-in is much easier to implement in at least some states. Right now New Mexico is aggressively pursuing a buy-in investigation. I think Nevada may be tempted to go down that path. Implementation requires a state to be in favor of a buy-in program and a friendly reading of waiver authority from the Center for Medicare and Medicaid Services (CMS). That duality may not be satisifed at the moment but a friendly to this type of waiver CMS is an easier lift than a Medicare for All friendly trifecta.

Medicaid buy-in programs are envisioned as supplements or complements to the Exchange/Marketplace structure. Emma and I looked at the different evaluation questions that need to be asked about these programs last March in Health Affairs:

There are two different policies that can be described as Medicaid buy-in programs. The first would be creating a new eligibility category for direct purchase of Medicaid by individuals with all of the attendant rights, obligations, and services that flow through Medicaid. This version of Medicaid buy-in requires modifications to state plan amendments and likely will require an 1115 waiver. The other policy would be to use the framework of Medicaid managed care contracts and networks to create metal plans for purchase on the Marketplace. Policy makers must identify which type of Medicaid buy-in they intend to use to communicate clearly their goals and objectives. Below, we present the various goals that policy makers may seek to achieve with Medicaid buy-in programs and how these goals should be evaluated…

  • Improve Coverage For The Current Individual Market
  • Provide Options For People Living In Regions With Limited Choices Of Health Plans 
  • Improve The Viability Of The Private Insurance Marketplace
  • Reduce Premiums For Consumers In The Private Insurance Market
  • To Provide People With A Guarantee Of Coverage With State-Mandated Consumer Protections
  • Improve The Financial Viability And Contracting Power Of The Medicaid Agency

A well-designed Medicaid buy-in program won’t achieve all of these goals. It may only intend to achieve one or two of these goals.

I think that Medicaid buy-in is one area of promising state-level experimentation that has a reasonable chance of implementation before 2023. The fact that there is a broad base of support and little concentrated opposition merely increases the probability of state level experimentation. This is where the action will be over the next couple of years for states, politicians, and activists that want to continue to expand coverage.