South Carolina’s Senate passed a medical marijuana legalization bill on Wednesday, sending it to the House of Representatives for consideration.

The vote on third reading passage was 24-19 and came one day after the body gave initial approval to the legislation from Sen. Tom Davis (R), which if enacted will allow medical cannabis access for patients with certain health conditions.

In order to get to the desk of Gov. Henry McMaster (R), the bill still needs to clear the House—a prospect that’s far from certain. The Senate had passed an earlier version of the legislation in 2022 but it stalled in the opposite body over a procedural hiccup.

Davis said during last week’s initial Senate debate on the current bill that his goal has always been to “come up with the most conservative medical cannabis bill in the country that empowered doctors to help patients—but at the same time tied itself to science, to addressing conditions for which there’s empirically based data saying that cannabis can be of medical benefit.”

“I think when this bill passes—and I hope it does pass—it’s going to be the template for any state that truly simply wants to empower doctors and empower patients and doesn’t want to go down the slippery slope” to adult-use legalization, he said. “I think it can actually be used by several states that maybe regret their decision to allow recreational use, or they may be looking to tighten up their medical laws so that it becomes something more stringent.”

Davis said during last week’s initial Senate debate on the current bill that his goal has always been to “come up with the most conservative medical cannabis bill in the country that empowered doctors to help patients—but at the same time tied itself to science, to addressing conditions for which there’s empirically based data saying that cannabis can be of medical benefit.”

“I think when this bill passes—and I hope it does pass—it’s going to be the template for any state that truly simply wants to empower doctors and empower patients and doesn’t want to go down the slippery slope” to adult-use legalization, he said. “I think it can actually be used by several states that maybe regret their decision to allow recreational use, or they may be looking to tighten up their medical laws so that it becomes something more stringent.”

Other changes that were adopted would prevent lawmakers and their immediate family members from owning or receiving compensation from medical marijuana businesses until 2029, ensure that vertically integrated businesses performing a certain function in the industry count against the total number of licenses allowed to be issued for that function, require dispensaries to have a pharmacist physically present on their premises during dispensing hours and further clarify that the definition of medical use does not include smoking.

The body had previously approved two amendments during second reading consideration on Tuesday.

One would make it so no more than three medical cannabis dispensaries could be located in any county. The other would clarify that regulators cannot prevent the “accurate listing of ingredients on a cannabis product that is a beverage,” with the sponsor of the amendment citing a recent letter from health officials that he said has “caused confusion” about the components of hemp-derived beverages.

Other changes that were adopted would prevent lawmakers and their immediate family members from owning or receiving compensation from medical marijuana businesses until 2029, ensure that vertically integrated businesses performing a certain function in the industry count against the total number of licenses allowed to be issued for that function, require dispensaries to have a pharmacist physically present on their premises during dispensing hours and further clarify that the definition of medical use does not include smoking.

The body had previously approved two amendments during second reading consideration on Tuesday.

One would make it so no more than three medical cannabis dispensaries could be located in any county. The other would clarify that regulators cannot prevent the “accurate listing of ingredients on a cannabis product that is a beverage,” with the sponsor of the amendment citing a recent letter from health officials that he said has “caused confusion” about the components of hemp-derived beverages.

Certain lawmakers have also raised concerns that medical cannabis legalization would lead to broader reform to allow adult-use marijuana, that it could put pharmacists with roles in dispensing cannabis in jeopardy and that federal law could preempt the state’s program, among other worries.

Here are the main provisions of the bill: 

• “Debilitating medical conditions” for which patients could receive a medical cannabis recommendation include cancer, multiple sclerosis, epilepsy, post-traumatic stress disorder (PTSD), Crohn’s disease, autism, a terminal illness where the patient is expected to live for less than one year and a chronic illness where opioids are the standard of care, among others.
• The state Department of Health and Environmental Control (DHEC) and Board of Pharmacy would be responsible for promulgating rules and licensing cannabis businesses, including dispensaries that would need to have a pharmacist on-site at all times of operation.
• In an effort to prevent excess market consolidation, the bill has been revised to include language requiring regulators to set limits on the number of businesses a person or entity could hold more than five percent interest in, at the state-level and regionally.
• A “Medical Cannabis Advisory Board” would be established, tasked with adding or removing qualifying conditions for the program. The legislation was revised from its earlier form to make it so legislative leaders, in addition to the governor, would be making appointments for the board.
• Importantly, the bill omits language prescribing a tax on medical cannabis sales, unlike the last version. The inclusion of tax provisions resulted in the House rejecting the earlier bill because of procedural rules in the South Carolina legislature that require legislation containing tax-related measures to originate in that body rather than the Senate.
• Smoking marijuana and cultivating the plant for personal use would be prohibited.
• The legislation would sunset five years after the first legal sale of medical cannabis by a licensed facility in order to allow lawmakers to revisit the efficacy of the regulations.
• Doctors would be able to specify the amount of cannabis that a patient could purchase in a 14-day window, or they could recommend the default standard of 1,600 milligrams of THC for edibles, 8,200 milligrams for oils for vaporization and 4,000 milligrams for topics like lotions.
• Edibles couldn’t contain more than 10 milligrams of THC per serving.
• There would also be packaging and labeling requirements to provide consumers with warnings about possible health risks. Products couldn’t be packaged in a way that might appeal to children.
• Patients could not use medical marijuana or receive a cannabis card if they work in public safety, commercial transportation or commercial machinery positions. That would include law enforcement, pilots and commercial drivers, for example.
• Local governments would be able to ban marijuana businesses from operating in their area, or set rules on policies like the number of cannabis businesses that may be licensed and hours of operation. DHEC would need to take steps to prevent over-concentration of such businesses in a given area of the state.
• Lawmakers and their immediate family members could not work for, or have a financial stake in, the marijuana industry until July 2029, unless they recuse themselves from voting on the reform legislation.
• DHEC would be required to produce annual reports on the medical cannabis program, including information about the number of registered patients, types of conditions that qualified patients and the products they’re purchasing and an analysis of how independent businesses are serving patients compared to vertically integrated companies.

After Davis’s Senate-passed medical cannabis bill was blocked in the House in 2022, he tried another avenue for the reform proposal, but that similarly failed on procedural grounds.

The lawmaker has called the stance of his own party, particularly as it concerns medical marijuana, “an intellectually lazy position that doesn’t even try to present medical facts as they currently exist.”

Meanwhile, a poll released last year found that a strong majority of South Carolina adults support legalizing marijuana for both medical (76 percent) and recreational (56 percent) use—a finding that U.S. Rep. Nancy Mace (R-SC) has promoted.

When North Carolina launched Medicaid expansion on Dec. 1, state officials said the measure would provide health insurance to an estimated 600,000 low-income adults over a span of two years.

It took just two months to reach 58 percent of that goal. More than 346,400 newly eligible beneficiaries have been approved for coverage as of Feb. 1, according to data from the N.C. Department of Health and Human Services.

The fast pace of enrollment was one of several expansion-related success stories that DHHS leaders shared with lawmakers during last week’s meeting of the monthly Joint Legislative Oversight Committee on Medicaid. It was the first formal report the department had presented to the 14-person committee since expansion took effect.  

Expansion raised the state’s income limit for Medicaid, extending eligibility to people who make an annual income of up to 138 percent of the federal poverty level based on their household size ($25,820 for a family of three). The previous limit was 100 percent. 

Jay Ludlam, the state’s deputy secretary for Medicaid, told the committee that DHHS launched expansion “in a way that was member-focused.” About 273,000 adults who had been enrolled in Family Planning Medicaid, a limited-coverage program for reproductive health services, were automatically upgraded to full Medicaid coverage when expansion went live in December. 

“We ran the algorithm on the information that we had for that population,” Ludlam said. “We determined those individuals who would qualify for Medicaid expansion and those who wouldn’t, and we moved those individuals who [did] qualify onto expansion.”

That strategy, he said, allowed the department to hit the ground running. Most of the new beneficiaries gained Medicaid with little or no action needed on their end.

“Those individuals didn’t have to go into an office,” Ludlam said. “They didn’t have to call a DSS worker. They didn’t have to fill out a form. Effectively, they woke up on December 1st with a card in hand, and they were able to access the full Medicaid benefit on Day One.”

People who were not part of the initial wave of automatic enrollments have been signing up for Medicaid at a steady clip since expansion launched. Ludlam said DHHS is adding an average of 1,000 beneficiaries to the rolls each day — a number he believes will taper off in the coming weeks.

A disproportionate share of the state’s new enrollees are residents of rural, economically distressed counties. That isn’t entirely surprising, according to Ludlam. He said expansion was expected to have an outsize impact in rural areas. 

“Broadly, in some of these communities, we would have anticipated high enrollment,” he said. “These are areas where individuals are working potentially more than one job to make ends meet.”

‘Knocking on death’s door’

For people like DeAnna Brandon, the value of Medicaid can be measured in days rather than dollars.

Diagnosed with a rare blood cancer in 2022, the Rowan County resident was told she had less than three years to live unless she received a stem cell transplant. Brandon, whose story was first reported by NC Health News, couldn’t afford the expensive procedure without health insurance — and her biological window of opportunity was growing smaller.

The chemotherapy that helped Brandon manage the symptoms of her cancer threatened to cause irreversible damage to her cells, undermining the effectiveness of the transplant. The physical toll of the treatment also left her unable to work.

Danay Burke, 43, was released from prison on Nov. 1. Among the many tasks on her to-do list for reestablishing her life was to figure out how to manage her health care needs. But she left prison without health insurance, making that a difficult and costly prospect.

“It’s slowing down the process of me helping myself,” Burke said.

She said she needs a drug assessment, medications for her anxiety and depression, birth control, a mammogram and a sleep study. However, Burke said she’s delayed all this care because she lacked medical coverage. 

Burke, like many others released from incarceration, fell into a health insurance coverage gap. Historically, most people reentering society after incarceration were either uninsured or uninsurable. 

But that’s poised to change in North Carolina with Medicaid expansion that took effect on Dec. 1. 

The expanded eligibility rules allow people ages 19 to 64 whose incomes are up to 138 percent of the federal poverty level for their household size to gain coverage, allowing about 600,000 more low-income residents to join the state’s Medicaid rolls. Now, a single adult living in a one-person household is eligible if their annual income is $20,120 or less before taxes. 

This criteria allows substantially more justice-involved individuals — people who often work in low-paying jobs or struggle to find work because of their criminal history — to enroll in Medicaid. The program can cover a variety of services, including doctor visits, behavioral health treatments and prescription drugs.

It’s a welcome change for Burke and others, who now have a path to getting health insurance that can pay for needed medical care — particularly as they shift out of a prison that was mandated to provide health care, to finding care in the community on their own.

Burke heard she newly qualified for Medicaid coverage from a staff member at Benevolence Farm — a reentry program in Alamance County offering housing and employment to women recently released from North Carolina prisons where she is staying — who helped her apply in December. Burke said she was approved for coverage, and she is eager to take advantage of the benefits to start taking care of her backlog of medical needs when she receives her Medicaid card in the mail.

However, Burke can’t help but think how much easier the path could have been without that disruption in care.

“A lot of people don’t have access,” Burke said. “They aren’t able to take care of themselves properly. Your mental health is a big thing because if you can’t take care of your mental health, a lot of people end up turning back to drugs and back to prison because we’re not able to take care of ourselves mentally and emotionally. 

“It’s a big, big issue.”

The state prison system releases more than 15,000 people into the community each year, and prison officials estimate that 80 percent of them are now eligible for Medicaid. 

They also recognize that inadequate access to health care can create a barrier to successful reentry into society. That’s why the N.C. Department of Adult Correction is working to ensure that fewer people are released into health care coverage gaps by helping people apply for Medicaid before they’re scheduled to leave prison.

“One of the key things with reentry is that break in service can really be detrimental,” said George Pettigrew, deputy secretary for rehabilitation and reentry at the N.C. Department of Adult Correction. “Somebody can decompensate real quick with mental health issues, substance use issues. If they don’t have that insurance ready to go where they can go and have these [health] services, that can be a problem.”

Gaining coverage

Mary Grillo, interim social work director and Medicaid expansion coordinator at the Department of Adult Correction, said the prison system has launched a department-wide effort to help people ages 19 to 64 who are within 90 days of their release date to apply for Medicaid coverage. 

That effort is in line with one of the goals outlined in the state’s participation in Reentry2030, a national initiative that aims to dramatically improve reentry success. North Carolina joined the initiative through Gov. Roy Cooper’s January executive order seeking to boost reentry support.

Reaching people about 90 days ahead of time is important, Grillo said, because it can take up to 45 days for a Medicaid application to be processed and eligibility determined. The goal is to have as many people as possible covered before their release, she said.

“It’s one less thing that the individual has to do when they get out of prison,” Grillo said. “It’s one less thing to worry about.” 

Grillo said prison staff, including three temporary workers hired in January to assist with the application process, are submitting about 100 Medicaid applications per week. 

“The biggest challenge is getting the information out there and getting the education out there and letting people know that this is available,” Grillo said.

To spread the word about the new opportunity for Medicaid coverage upon release, the prison system has distributed a flyer through electronic tablets that are available to all incarcerated people and hung paper flyers on bulletin boards across prisons.

A slew of states are pursuing Medicaid coverage for incarcerated populations ahead of their release from prison as a means to address substance use disorders. 

In Jan. of 2023, California received federal approval to provide people in correctional facilities with Medicaid services before their release.

One year later, a “groundswell” of other states seek to make similar strides in the hopes of reducing the rates of overdose-related death and other health care problems that are exacerbated in the weeks immediately after an incarcerated person’s release. 

“There’s really a groundswell of state interest,” Vikki Wachino, founder and executive director of the Health and Reentry Project (HARP), told Addiction Treatment Business.

HARP is an initiative that seeks to advance policy and practices that improve the lives, health and safety of incarcerated people as they return to their communities.

“We see very poor health outcomes after people leave prison and jail,” she continued.
“We see it across a range of conditions … but the real standout is with respect to opioid overdoses, where the rate of opioid overdose deaths for people right after they leave prison or jail is significantly higher than it is for the population as a whole.”

More states are following the example set by California, which submitted an 1115 waiver petitioning the federal government to amend the federal law prohibiting Medicaid from covering most services when people are incarcerated.

Other states have followed suit. Washington’s waiver was already approved, and other states are awaiting CMS approval.

These waivers, or other legislature like them, will soon be all but universal, industry experts told Addiction Treatment Business.

“It’s about health care, but it’s also about giving people second chances and the difference that health care can make between life and death,” Wachino said.

The problem: heightened rates of overdose deaths

Mental illness and substance use disorders are disproportionately prevalent among incarcerated people.

Around 18% of the general population is estimated to have a mental illness, compared to 44% of people in jail and 37% of people in prison, according to the Substance Abuse and Mental Health Services Administration (SAMHSA).

Among the general population, approximately 11% of people aged 18 to 25 have an SUD, as well as approximately 6% of people over 25 years old. The rates skyrocket among incarcerated people, with approximately 63% of people in jail and 58% of people in prison having an SUD.

“Because of the war on drugs, we’ve criminalized substance use,” Meghann Perry, a recovery coach professional educator and person with lived experience of substance addiction and incarceration, previously told Behavioral Health Business. “Therefore, the vast majority of people who are incarcerated, it’s related in some way to substance use.”

Incarceration can exacerbate symptoms of SUD and make it more challenging to get appropriate treatment. These problems, in turn, can lead to people staying incarcerated for more extended periods.

The transition from incarceration back into the general population can be perilous for those with SUD. People incarcerated in state prisons are 129 times more likely to die from an overdose compared to the general public, according to a study published in the New England Journal of Medicine. 

The increased risk immediately post-release is due to the isolation of prison, according to Cooper Zelnick, chief revenue officer at Groups Recover Together.

“What we have observed, and we have data on this because we’ve been doing transitional care and reentry planning work with departments of corrections for years, is that if you can get an individual plugged into treatment within the first 24 to 48 hours after release,” Zelnick said, “you can massively reduce fatal overdose, relapse and recidivism, which of course has a significant benefit from a societal cost perspective.”

Woburn, Massachusetts-based Groups Recover Together provides SUD treatment using Suboxone, a brand name of buprenorphine, along with group therapy to promote members’ recovery through in-person or virtual care models.

“We’d be able to provide them much better medical care and behavioral health care while incarcerated, which would really support them doing much better when they transition back into the community and not have that gap,” Perry said.

“The primary barrier,” Zelnick added, “Is that most treatment providers won’t provide treatment unless they’re reimbursed for it.”

The solution: passing 1115 waivers for incarcerated people

One method of breaking down that barrier is through an 1115 waiver designed to provide incarcerated people with Medicaid access prior to their release.

“The waivers basically build a bridge to help people access services right after release,” Wachino said.

The “bridge” covers a targeted set of services while still incarcerated, creating connections to community services.

“We’d be able to provide them much better medical care and behavioral health care while incarcerated, which would really support them doing much better when they transition back into the community and not have that gap,” Perry said.

California was the first state to receive federal approval to provide people in prisons, jails and youth correctional facilities with some Medicaid and Children’s Health Insurance Program (CHIP) services through an 11115 waiver called the California Advancing and Innovating Medi-Cal (CalAIM).

California’s waiver “blazed the path with CMS,” and now other states are following suit.

Two states, California and Washington, have approved waivers, and 16 other states have currently pending proposals.

“It’s really notable that a number of those states, like New Hampshire and West Virginia, have a specific focus on substance use or mental health services as part of their waiver,” Wachino said. “What we see here is governors and legislators of both parties looking to reentry waivers as a tool to address some of the national challenges that we face with respect to substance use overdoses and mental health.”

According to industry experts, both sides of the political aisle are supportive of addressing substance use disorders and related issues. 

New Hampshire’s waiver, called ​​”Substance Use Disorder Serious Mental Illness and Serious Emotional Disturbance Treatment Recovery and Access,” would provide a limited package of care coordination services to incarcerated people in state prisons who are receiving treatment for SUD, opioid use disorder (OUD), serious mental illness (SMI) or serious emotional disturbance (SED).

West Virginia, Montana and Kentucky are also among the states with waivers that mention SUD.

Even among states that have not yet proposed similar waivers, the impact of California’s progress has sparked change.

“The state of Maine has, since 2018, received grants to serve the uninsured that are primarily designed to bridge that gap between incarceration and Medicaid coverage,” Zelnick said. “I imagine that this will be a thing that happens everywhere.”

States are motivated to follow in California’s footsteps partly because of potential cost savings.

“If you can give people access to benefits, they are much more likely to pursue care,” Zelnick said. “That care is likely to have a positive impact on recidivism, which massively reduces the cost center that is our criminal justice system, and on top [of that, you get positive] health outcomes, so it’s win-win.”

The waivers attract little criticism but have garnered questions on how the policies will be implemented.

“I think that’s a very valid question,” Wachino said.

To properly implement 1115 waivers, states must “set a big table” for the conversations to come, Wachino said, with place settings for correctional officials, health care providers, law enforcement officials, managed care plans and people who have themselves been incarcerated.

As California and Washington both work on implementing their approved waivers, more states will follow their examples.

“I imagine that this will be a thing that happens everywhere,” Zelnick said. “It’s still really tricky for a whole bunch of reasons. But the trend is moving in the right direction here.”

The waivers have the potential to be “groundbreaking,” Wachino said.

“It is a real opportunity to connect people to services and strengthen their health and the health of the communities that they live in,” she said. “This is a very substantial step forward, both by state and federal leaders.”

A new report by the Elevance Health Public Policy Institute underlines the positive health impacts of doula access on pregnant patients. Elevance Health provides Medicaid managed care plans nationally, including in Texas through Wellpoint.

The institute found that overall, patients had better birth and postpartum outcomes when accessing doula services. Researchers measured Medicaid patients across the health system’s locations and compared those who had a doula to those who did not.

Patients who used doula care were often Black and lived in communities with a shortage of OBGYN and maternal care. Jennifer Kowalski, the vice president of the public policy institute, said the organization intentionally did outreach to patients who were at higher risk for pregnancy complications.

She said even though these patients were at higher risk, the report still found “better outcomes among those [people]. That’s an important thing to underscore and perhaps somewhat surprising.”

The report found that people who worked with a doula had lower rates of C-sections and lower postpartum anxiety and depression. Patients were also more likely to attend their postpartum visits.

“I think doula services for folks who are pregnant is an important part of [a] whole health approach,” Kowalski said.

The report recommends states lower barriers for doula services to be covered by Medicaid. Midwives and free-standing birth centers are covered under Medicaid in Texas, but doulas are not.

Last year, Texas lawmakers introduced legislation to create a pilot program for doulas to be covered under Medicaid, but the bill stalled in committee.

“Expanding access to doula services more broadly is really the hope,” Kowalski said. “Over time, knowing that we’re seeing such positive results from our study…that this encourages investment in doula workforce and that [patients] who need these services can access them more widespread than they do today.”

Texas did pass and get federal approval for 12 months of postpartum coverage, which goes into effect March 1.

Advocates, birth workers and researchers have said this extended coverage will lower the rates of maternal mortality and morbidity in the state.

Got a tip? Email Elena Rivera at erivera@kera.org

More than 16 million Americans have lost Medicaid coverage in recent months, according to data from the Kaiser Family Foundation. Two million Texans have rolled off Medicaid, newly released state data show. That’s good news, despite what the Biden administration would have us believe.

For decades, Medicaid has burdened taxpayers with billions of dollars in wrongly allocated payments while providing beneficiaries substandard care. Taxpayers and beneficiaries themselves would be well served by a swift process of redetermining whether those currently enrolled in the program are actually eligible — and reforms that make private insurance more affordable.

The size of Medicaid has swelled in recent years. During the pandemic, the federal government restricted states’ ability to “disenroll” people who no longer qualified, often because they’d moved up to a higher income level.

As a result, Medicaid enrollment increased by more than 23 million people between February 2020 and April 2023. Total enrollment was nearly 95 million at its peak.

Even in Texas, which did not expand Medicaid under the terms of the Affordable Care Act and has some of the tightest criteria for eligibility in the country, enrollment surged during the pandemic. Nearly 6 million people — about one in five Texans — had coverage through Medicaid and the state Children’s Health Insurance Program in May 2023.

After the COVID public health emergency ended last spring, states resumed “redetermination” procedures to establish Medicaid eligibility. Progressives are warning that millions of low-income Americans could end up losing Medicaid by mistake — say, by failing to respond to a letter requesting that they prove they’re eligible.

Such scaremongering is unwarranted. Anyone wrongfully disenrolled can sign up again. And in most states, including Texas, those folks can also get several months’ worth of retroactive coverage.

It’s far likelier that those being disenrolled shouldn’t be on the program at all.

According to the Congressional Budget Office, nearly 13 million Medicaid enrollees in 2022 weren’t eligible and had simply been kept on due to pandemic rules. Payments for these extra enrollees amount to waste.

And Medicaid’s issues with waste, fraud, and abuse run deep. In 2023, it distributed more than $50 billion in “improper payments” — expenditures for the wrong people or at the wrong amount.

Things were worse before redetermination. In 2021, Medicaid’s improper payments reached nearly $100 billion. That year, the program spent a staggering one in every five dollars incorrectly.

Even Medicaid’s proper payments are inefficient. The program, which now costs taxpayers north of $800 billion annually, spends nearly three times more per patient than employer-sponsored plans.

Many state officials are rightly trying to stop this waste through redetermination. Government shouldn’t squander money earmarked for the vulnerable on those who qualify for cheaper care elsewhere.

The Urban Institute estimates that most of the 18 million Americans projected to lose Medicaid during redetermination will get comparable coverage through the Children’s Health Insurance Program, the individual market, or some kind of employer-sponsored insurance.

Of the 3.8 million projected to become temporarily uninsured, roughly half will “have access to subsidized coverage, principally a subsidized exchange plan,” according to Brian Blase of the Paragon Health Institute.

There’s plenty the government could do to help disenrolled beneficiaries obtain quality coverage.

To start, the federal government could give low-income Americans vouchers to spend on employer-sponsored or other private health plans in lieu of the federal subsidies they’re already entitled to. Those funds could go into health savings accounts, or HSAs, where people can stow money tax-free for future health needs. Patients could access the money using a bank-issued debit card reserved for medical bills, as a paper published by the Paragon Health Institute recently proposed.

Incentivizing people to use HSAs would save money for virtually all taxpayers and prove especially valuable for lower-income Americans. According to one estimate, nearly seven in 10 Obamacare enrollees below 200% of the federal poverty line would benefit from an HSA option, with the average beneficiary saving around $1,500 per year.

Lawmakers should also expand ways for employers to offer coverage. That means loosening regulations so it’s easier for companies to purchase association health plans. These group plans cover multiple businesses, making insurance more affordable for startups and entrepreneurs with tight budgets.

Congress should also enshrine a Trump-era executive order that lets employers reimburse their employees for qualified health expenses, including Obamacare premiums. That way, employers can offer health benefits without purchasing a company-wide plan.

Medicaid should not be the largest health insurer in the country. The program exists to serve those who truly can’t afford care. States are rightly pushing a return to that original purpose by disenrolling those who don’t qualify.

©2024 Fort Worth Star-Telegram. Visit star-telegram.com. Distributed by Tribune Content Agency, LLC.

By far the biggest thing about the great Medicaid unwinding of 2023 is the number of low-income people who have been disenrolled, and we have been tracking that relentlessly at KFF. More than 16 million people have been disenrolled so far, as continuous Medicaid coverage provided during the pandemic ended, based on the most current data from all 50 states and the District of Columbia. About 70% of the disenrollments were for procedural reasons. Many people dropped will get coverage elsewhere, through an employer or the Affordable Care Act marketplace, and some who are still eligible will make their way back to Medicaid. The big question is how many will end up uninsured. The picture will vary across states, as it always does when it comes to covering the low-income population.

But there is another story in the data that goes with the unwinding that has mostly escaped notice. We are seeing a decline in federal Medicaid funding as fiscal relief to states in the form of higher matching funds is withdrawn, and an increase in state Medicaid spending, despite lower enrollment. And it’s happening when revenues in most states are weakening. That can be expected to put pressure on state budgets, rekindle on again off again conflict in states about the share of the budget consumed by Medicaid, and make it tougher for states to continue current efforts to strengthen their Medicaid programs.

A few numbers:

• The Congressional Budget Office projects that states will receive $58 billion less in federal Medicaid outlays in FY 2024 than they did in 2023. As a consequence, states report that their Medicaid spending will increase by 17.2% in FY 2024.
• State revenue collections have started to slow down or decline, and some states may have to face budget gaps in the coming years.  States have recently experienced an overall 2% decline in inflation adjusted revenues.
• Most of the state numbers are estimates and projections. They are often the product both of best estimates and political calculus, but over the years, they’ve generally been in the ballpark.
• States are spending to address rising costs in Medicaid and health care, but also long overdue needs, such as increasing some providers payment rates or putting more resources into home and community-based services or mental health and behavioral health services. States like California and North Carolina are making big plays to address the social determinants of health outcomes for targeted populations. These are some of, if not the most innovative programs in health care.

Medicaid will face blowback in state budget wars in many states as it eats up a larger share of the new funds available in state budgets that legislatures, cabinet agencies, and governors will want to direct to other priorities. When I was Human Services Commissioner in New Jersey, I had eight divisions and a third of the state budget and workforce in NJ HHS (the department has long since been reorganized and reduced in size). One division was Medicaid. The competition for new funds was fierce even within my own department when times were good. In state budget politics, only so much of the annual increase in a state budget will go to one department, no matter the need.

As always there will be variation among states. Where governors have made Medicaid initiatives a personal priority, they may sustain them despite revenue and budget challenges, even cutting elsewhere in Medicaid and social services to continue favored projects.

In our large survey of consumers, Medicaid generally competed well with Medicare, Marketplace and employer coverage, with each type of coverage presenting consumers with the kinds of barriers to care and frustrations common to health insurance today.  But Medicaid programs face their own challenges, including access to many specialists.

The question for the next several years is whether states will be able to continue to make targeted new commitments to strengthen Medicaid and mount innovative new programs in an environment of declining federal matching funds, weakening state revenues and competing state priorities. Medicaid is a counter-cyclical program and these are far from the worst circumstance states have faced. The election obviously can have significant additional consequences for Medicaid, especially if Republicans control the White House and Congress, and return to proposals to block grant Medicaid and make significant cuts in federal funding. But that’s only a possibility, while these changes are already in the works, bringing with them shifting sands for Medicaid.

View all of Drew’s Beyond the Data Columns

Nurses in Santa Cruz, Calif., make more money on average than nurses in any other metro area, a Vivian Health ranking found.

Vivian Health used Bureau of Labor Statistics data to find the metro area in each state that paid nurses the highest wages. Rankings of metro areas were based on the dollar difference between a registered nurse's median annual salary and the median salary of all occupations in the area.

The ranking showed that nurses earn some of the highest wages relative to other occupations in the area. California had the highest wage among all states, while Iowa had the lowest.

Here is the top metro area in every state with the median annual wage for nurses:

Alabama — Daphne: $64,700

Alaska — Fairbanks: $107,880

Arizona — Yuma: $82,290

Arkansas — Little Rock: $71,460

California — Santa Cruz: $175,350

Colorado — Pueblo: $82,780

Connecticut — Danbury: $105,370

Delaware — Dover: $78,320

Florida — Sebastian: $79,190

Georgia — Rome: $81,320

Hawaii — Urban Honolulu: $127,020

Idaho — Coeur d'Alene: $83,730

Illinois — Kankakee: $80,470

Indiana — Michigan City: $72,720

Iowa — Sioux City: $62,860

Kansas — Lawrence: $67,150

Kentucky — Owensboro: $78,040

Louisiana — Shreveport: $77,790

Maine — Bangor: $83,750

Maryland — Salisbury: $79,210

Massachusetts — Leominster: $96,410

Michigan — Flint: $86,210

Minnesota — St. Cloud: $85,730

Mississippi — Hattiesburg: $59,910

Missouri — St. Louis: $77,390

Montana — Missoula: $76,550

Nebraska — Grand Island: $74,290

Nevada — Las Vegas: $95,770

New Hampshire — Manchester: $80,560

New Jersey — Ocean City: $85,490

New Mexico — Las Cruces: $78,270

New York — New York City: $103,540

North Carolina — Fayetteville: $82,390

North Dakota — Fargo: $75,710

Ohio — Canton: $74,950

Oklahoma — Lawton: $77,070

Oregon — Bend: $108,310

Pennsylvania — Chambersburg: $84,090 

Rhode Island — Providence: $84,770 

South Carolina — Spartanburg: $81,520 

South Dakota — Rapid City: $62,920 

Tennessee — Cleveland: $76,620 

Texas — Wichita Falls: $79,800 

Utah — Provo: $75,090 

Vermont — Burlington: $77,230 

Virginia — Winchester: $81,940 

Washington — Spokane: $100,280 

West Virginia — Huntington: $77,240 

Wisconsin — Racine: $77,960 

Wyoming — Cheyenne: $81,680 

Feb. 1 (UPI) -- A RAND Corporation report released Thursday found that U.S. prescription drug prices are much higher than in other nations.

The report is out on the same day that Medicare sent initial price negotiating offers on 10 drugs for seniors.

According to the study, U.S. drug prices average 2.78 times the prices charged in 33 other countries studied.

For brand name drugs, it's even more pronounced, with U.S. prices for those kinds of drugs being 4.22 times higher than drug prices in other countries.

For insulin, RAND found U.S. prices ranged from 457% higher than Mexico to 3,799% higher than prices in Turkey.

"These findings provide further evidence that manufacturers' gross prices for prescription drugs are higher in the U.S. than in comparison countries," said report lead author Andrew Mulcahy in a statement. "We find that the gap is widening for name-brand drugs, while U.S. prices for generic drugs are now proportionally lower than our earlier analysis found."

Medicare on Thursday sent initial pricing offers to U.S. drug manufacturers aiming to lower medicine costs for families.

The White House said in a statement that Big Pharma is using nine lawsuits against the Medicare Drug Price Negotiation that was in the Biden Administration's Inflation Reduction Act.

According to the RAND report, U.S. prescription drug prices are 1.72 times higher than in Mexico while they are 10.28 times more expensive than prescription drugs in Turkey.

The U.S accounts for 62% of the total drug spending in the nations RAND studied while it accounts for just 24% the drug volume sold.

The study was sponsored by the Office of the Assistant Secretary for Planning and Evaluation in the U.S. Department of Health and Human Services.

The study looked at pricing in the Organization for Economic Cooperation and Development countries.

According to RAND, estimates are that prescription drug spending in the United States accounts for more than 10% of all health care spending.

Retail prices for prescription drugs in the United States rose by 91% between 2000 and 2020. It's expected to go up 5% a year annually through 2030.

The RAND report "International Prescription Drug Price Comparisons Estimates: Using 2022 Data" is available at www.rand.org.

As readers of Say Ahhh! know, I have been tracking monthly data (here, here, here, here, here and here) from the Centers for Medicare and Medicaid Services (CMS) on the number of people who were either previously enrolled in Medicaid or had experienced a denial or termination during unwinding who then selected a marketplace plan.  At the end of January, CMS issued new data for October 2023.  (For an overall status update on Medicaid unwinding, see this blog from my CCF colleague Joan Alker.)

In September, another 1.62 million people lost their Medicaid coverage due to unwinding of the Medicaid continuous coverage protection, of which 68.9 percent were procedural disenrollments and 31.1 percent were due to a finding of ineligibility.  Separately, CMS reported that nearly 393,000 people who were either previously enrolled in Medicaid in federal marketplace states or had experienced a denial or termination in state-based marketplace states selected a marketplace plan in the same month.  That constituted about 24.3 percent.

Compared to total marketplace enrollment among those losing Medicaid in September, October marketplace enrollment was nearly 77 percent higher.  (Virtually all of this marketplace enrollment increase occurred in federal marketplace states.)  As a result, the rate of marketplace enrollment among those disenrolled from Medicaid increased substantially, compared to only 13.4 percent in September. (In addition, another 36,000 or 2.2 percent enrolled in a Basic Health Plan in New York and Minnesota in September, with nearly all of that BHP enrollment occurring in New York.)  Cumulatively, through October 2023, compared to the 10.8 million people disenrolled from Medicaid, about 1.4 million or still only 13.3 percent enrolled in marketplace plans.  (The figure rises to 15.1 percent if including Basic Health Plan enrollment.)

As each of the blogs about previous CMS data releases noted, to provide context to these figures, last year, federal researchers from the HHS Office of Assistant Secretary for Planning and Evaluation (ASPE) projected that of the 15 million people expected to lose Medicaid during the unwinding, nearly 2.7 million people — or about 18 percent —would be eligible for subsidized marketplace coverage.  While this data represents only the outcome of unwinding through October, it indicates that overall transitions to marketplace coverage is still falling short of the expected pace.  This is despite overall marketplace enrollment soaring to a historic high of 21.3 million during the 2024 Open Enrollment Period and the welcome surge in successful marketplace transitions for those disenrolled from Medicaid in October.

Moreover, at the current pace of disenrollments, the total number of people disenrolled from Medicaid once unwinding is completed is highly likely to far exceed the original 15 million projection from ASPE, and even the 17 million projection from other analysts such as KFF.  And the share of total disenrollments that are procedural terminations — 71 percent according to our latest data — is well above the 45 percent estimate from the ASPE projections of the number of eligible people disenrolled for procedural reasons.  Finally, for children losing Medicaid, even with the enhanced marketplace subsidies, children accounted for only about 9 percent — or 1.55 million — of total marketplace enrollees during the 2023 Open Enrollment Period.  (Data on the child share of marketplace enrollees during the 2024 Open Enrollment Period is not yet available.)

Marketplace plans will be a valuable source of affordable, comprehensive health coverage but only for a relatively modest number of people, especially children, who lose their Medicaid coverage during unwinding.  Instead, it’s critical for state Medicaid programs, as they complete the unwinding process in coming months, to reduce the persistently high rates of procedural terminations for children, parents and other adults, many of whom, especially children, are likely to remain eligible for Medicaid.  This includes states continuing to increase ex parte renewal rates, ensuring full compliance with all federal requirements for Medicaid renewals and taking up more of the renewal flexibilities provided by CMS, such as pausing all Medicaid renewals for children for one year as Kentucky and North Carolina have recently done.

At the same time, to increase child Medicaid enrollment to offset these large coverage losses from unwinding, states should also take up various actionable strategies to promote continuous coverage for children and families, as recently reinforced in a CMS Informational Bulletin issued in December.  States should also take up multi-year continuous eligibility for children, which an increasing number of states are adopting, in addition to successfully implementing mandatory 12-months continuous eligibility for children which took effect on January 1, 2024.  Finally, states and the federal government will need to work together on robust outreach and enrollment efforts in 2024 to target eligible children, families and other adults who were disenrolled for procedural reasons so they can be reenrolled in Medicaid as quickly as possible.