Tuesday’s election made Maine the 32nd state to expand Medicaid coverage under the ACA.   A ballot initiative to require the expansion was approved by Maine voters with nearly 59 percent of state voters approving the expansion.  Governor Paul LePage (R-ME) has blocked expansion since 2012 and he says he will continue to block expansion.  He has said that the legislature will have to figure out how to find the $54 million in state funds that would leverage more than $525 million in federal Medicaid funding that would expand coverage to 70,000 Maine residents.

If all 19 states that are resisting expansion would expand coverage, an estimated 6 million more people would have health coverage nationally.  If a state takes the expansion option (made into an option by the Supreme Court in 2012), they expand to families up to 138 percent of poverty at a high match federal match rate that has the federal government picking up 90 percent of the costs.  The action by Maine voters may cause other states and advocates to seek the election initiative route to expansion. Advocates are also looking at Virginia where the control of the House could flip over (pending recounts) giving incoming Governor Ralph Northam (D-VA) more leverage over a legislature that has blocked expansion against efforts under Governor Terry McAuliffe (D-VA).

Open enrollment to sign-up or change health care coverage under the ACA started on Wednesday. November 1, (and ends on Friday, December 15, 2017) and despite the Administration and Congressional efforts to kill the ACA, the  HealthCare.gov not only began without problem but sign ups surged in the first days.  In the first four days, HHS acknowledged that enrollment was about twice the pace of last year with an average of about 150,000 a day signing up or more than 600,000 in the first four days.  Last year 12.2 million enrollments had taken place through the federal exchange.

These enrollments do not include those enrollments through the 11 state run exchanges which also appear to be experiencing increased traffic. New York is one of those states with its own exchange.  Officials said that more than 140,000 visitors checked out their options on the website while 73,000 customer service calls were made.  The website numbers represent a 30 percent increase in traffic compared to last year.

In a development that was clearly unintended by the President, every county in the country will have at least one plan that is free to low-income families.  That analysis is by Avalere Health and it is because the tax credits are based on the higher cost of premiums based on the “silver plans”—the third level out of 4 plans.  Those plans saw an average increase that was double digit but in driving up those average premiums some low-income people can now use higher tax credits and buy the cheapest bronze plans and others may be able to buy up to the more expensive gold plans.

There was at least one Washington-publication report that the President is crafting a new executive order to gut the individual mandate (i.e. the requirement that people have health insurance).  There were denials by the Administration but apparently the President’s earlier Executive Order to weaken the law did not prevent the IRS from following the law which requires people to pay a tax penalty if they fail to have coverage.

Senator Orrin Hatch (R-UT) is working on a draft bill along with Senator Mike Crapo (R-ID) to create a super waiver bill that would allow much easier access to ACA and Medicaid waivers and allow governors to bypass their own state legislators.  The bill goes well beyond the compromise that was reached by Senator Lamar Alexander (R-TN) and Senator Patty Murray (D-WA).

The mandate could get repealed in either Congressional tax reform bill.  Talks and rumors bounced back and forth all last week that either the House and/or the Senate would include a repeal of the individual mandate.  That did not happen in the Committee passed tax bill in the House and is not in the Senate description, so far.  There was a Congressional Budget Office score that said a repeal would save the Treasury $338 billion over ten years.  That $338 billion is a tempting target for members who want to add to the tax cut package.  The savings is because 15 million fewer people would have health insurance, first because healthier individuals will drop out and second because with healthier people dropping coverage the remaining pool would face higher premiums that would force some people off health insurance.  The loss in coverage means few tax credits to buy insurance.  As the two tax bills move forward, the mandate will continue as a big target.