1. Medicaid Opportunities & Challenges Task Force May 13, 2013 Jeff Bechtel, Senior Consultant National Medicaid Expansion Update

2. Review of Medicaid Expansion Activity State Snapshots North Dakota Montana Wyoming Iowa Minnesota Source: Composites from publicly-available Medicaid Expansion tracking services Presentation Overview 2

3. The expansion map has basically been unmoved for weeks. West Virginia Gov. Earl Ray Tomblin was the last Democratic governor to remain undecided. Announced in early May that he is pushing ahead with expansion. Some Republican governors (AZ, OH, NJ, FL, NV, NM, MI, ND) are in favor of moving forward with Medicaid Expansion, but most have to date failed to win legislative support. Of the nine, only North Dakota Governor Jack Dalrymple has succeeded in pushing legislation through his state Legislature. Other governors are delaying a decision as they gather more feedback. Medicaid Expansion Activity 3

4. As state legislatures wind up their 2013 sessions, some Governors are contemplating special sessions and others plan to take a new look next year. The most significant development occurred in Arkansas, when Republican lawmakers and Democratic Gov. Mike Beebe embraced a plan to buy private sector coverage for the state’s Medicaid-eligible population. Approach signed into law in late April, 2013. Uncertain if plan will receive federal approval. Medicaid Expansion Activity (cont’d) 4

5. Some Governors have already signaled their intent to either opt-in or opt-out of the expansion. However, many states have not taken a definitive position. In some cases, Governors and state legislative leaders have offered differing opinions. Here is a preliminary snapshot of where states stand based on news reports and statements by Governors.* * Kaiser Family Foundation analysis as of May 10, 2013. Subject to change. Reflects updated information from South Dakota Governor’s Office. Where States Stand Now on Medicaid Expansion 5 Executive Status: Proposing expansion: 29 Not proposing expansion: 20 Weighing options: 1

6. State Governance: Gov. – R; House – R; Senate – R In July, 2012 a spokesperson for Gov. Jack Dalrymple (R) said the governor had not yet decided whether to participate in the Medicaid expansion. Re-elected in November 2012, Gov. Dalrymple did not include funds for the Medicaid expansion in his 2013-2015 budget recommendations, but he did submit a bill to the state legislature that would implement the expansion. State Snapshot – North Dakota 6

7. In January, the Gov. expressed support for the bill and noted that his budget proposal would include an expansion plan. On Feb. 27, 2013 the Republican-led state House approved legislation authorizing the state to expand Medicaid. Leading GOP members said that doing so is in the best interest of the state in terms of reducing health care costs. State Snapshot – North Dakota (cont’d) 7

8. State Governance: Gov. – D; House – R; Senate – R Outgoing Democratic Gov. Brian Schweitzer filed a budget on November 15, 2012 that would expand Medicaid coverage to 80,000 Montanans. His successor, Gov. Steve Bullock (D) filed a revised budget on January 4, 2013 retaining the proposal to expand Medicaid. State Snapshot – Montana 8

9. Gov. Bullock used his 2013 State of the State Address as a platform to urge those opposed to the expansion to “take the longer view” by “focusing on the health and welfare of our neighbors.” House Democrats developed and introduced Medicaid Expansion Legislation, but it was rejected after a voting mishap. The Governor is reportedly considering a special session, and expansion supporters in the state have already talked about putting it on the ballot next year. State Snapshot – Montana (cont’d) 9

10. State Governance: Gov. – R; House – R; Senate – R Gov. Matt Mead (R) did not include any funding for the Medicaid expansion in his latest budget, telling lawmakers that he “will not commit the state to a Medicaid expansion, until and if our questions are answered.” Gov. Mead emphasized that whether or not Wyoming should expand Medicaid “is an important discussion” that “needs to occur in the Legislature.” Gov. Mead asked “the Legislature to look hard at all sides [of a potential expansion]” and expressed his desire to resolve this issue before the end of the current legislative session. The state legislature will make the final decision on whether to expand the program. State Snapshot – Wyoming 10

11. State Governance: Gov. – R; House – R; Senate – D On July 2, 2012 Gov. Terry Branstad (R) said that Iowa will opt out of the expansion. Echoing this position in an August 22, 2012 interview, the governor’s spokesperson said the governor remains opposed to the expansion, and will likely pursue state- based efforts to make health insurance coverage more affordable instead. On February 24, 2013 Gov. Branstad again publicly rejected the expansion, “Because we think the whole thing in the end will either collapse or the burden will be pushed onto the states in a very significant way.” Instead, Gov. Brandstad pressed Secretary Sebelius for a federal waiver to continue IowaCare, a health care program that provides limited benefits to 70,000 low- income state residents. State Snapshot – Iowa 11

12. State Governance: Gov. – D; House – D; Senate – D On June 28, 2012 Gov. Mark Dayton (D) said "Today's ruling will be met with relief by the Minnesotans whose lives have already been improved by this law.” In 2011, Dayton used federal money to expand Medicaid early to 84,000 adults with annual incomes below $8,400. State Snapshot – Minnesota 12

13. Questions? Sellers Dorsey sellersdorsey.com Jeff Bechtel Senior Consultant Sellers Dorsey 717.695.4342 jbechtel@sellersdorsey.com 13