Minnesota has a proud history of ensuring the vast majority of its residents access to reasonable health coverage, no matter their income. In 2015, nearly 96 percent of Minnesotans were insured, thanks not only to the federal Affordable Care Act (ACA) and high rates of employer-sponsored coverage, but also to long-standing state-level policy choices. Minnesotans are more likely than U.S. residents generally to have a usual source of health care and far more likely than not to be confident they can obtain the care they need.
Much of this may be swept away under the incoming government in Washington. The new Congress and incoming president may have been put into office by voters angry about what they see as an overreaching federal government that has trampled on the rights of states and individuals to make their own choices about health care and other matters. Yet if they have their way, the money and federal legislation that gave Minnesota the freedom to be a national leader in health coverage over the last three decades may vanish.
Minnesota’s robust health coverage is based in part on its Medical Assistance and MinnesotaCare programs. Minnesota has long provided generous access to Medical Assistance to impoverished families, the disabled and the elderly. In 1992, bipartisan support led to the enactment of MinnesotaCare, which offers subsidized health coverage for low- and moderate-income Minnesotans who do not qualify for Medical Assistance but whose jobs do not offer coverage.
These programs are contingent on two federal policies. The first is funding. The federal government provides Minnesota with 50 percent of the funding for traditional Medical Assistance beneficiaries and more than 90 percent of the funding for beneficiaries newly covered under the ACA expansion. More important, that funding is uncapped, which means it increases as the coverage need increases.
Also key is federal flexibility. MinnesotaCare provides health coverage to populations that states typically cannot cover using federal Medicaid matching funds. Minnesota successfully obtained waivers from applicable federal law to use federal Medicaid dollars to help fund MinnesotaCare.
Medical Assistance and MinnesotaCare long predate the ACA. Yet the incoming government threatens their foundations. How? In 2013, the Minnesota Legislature transformed MinnesotaCare into a Basic Health Plan under the ACA. This changed the program’s primary source of funding from federal and state Medicaid dollars to federal premium and co-payment subsidies under the ACA. Those subsidies will likely be on the chopping block under the new Congress.
Why not just return to the old way of funding MinnesotaCare, using a federal Medicaid waiver? It is possible that Seema Verma, President-elect Donald Trump’s choice to head the Centers for Medicare and Medicaid Services, would be amenable to such a waiver request. However, if it were granted, there might be little funding available for it. Both Trump and key Republicans in Congress support some form of cap on federal Medicaid dollars. General caps are unprecedented in the 51-year history of Medicaid, but they may be forthcoming unless protests from states, hospitals, beneficiary advocates and other stakeholders are successful.
It’s true that funding caps might also bring reduced federal regulation. But that would yield false freedoms. Minnesota might be free to offer the generous benefits it currently does, but only to the poorest Minnesotans. It might be free to offer benefits to low- and moderate-income Minnesotans, but only to cover a few primary care visits and prescriptions. It might be free to expand the number of covered Minnesotans in a recession, but it might have to cut benefits to the bare bone.
Do we, the voters of Minnesota, really want the state to be forced to cut long-standing health benefits? Minnesota chose to be a leader in health coverage long agoand has, in many respects, stuck to it steadfastly. We should clearly tell our representatives in the incoming Congress not to eliminate that choice.
Laura Hermer is a professor at Mitchell Hamline School of Law.