OK on Medicaid could spell relief for counties

Key Takeaways

The consequences resulting from the voter-driven Medicaid expansions in three states — Utah, Nebraska and Idaho — will remain to be seen, but state associations see potential for at least a little relief for counties that have to provide health care.

Montana voters voted against Medicaid expansion, which would have been been funded with an increase in the tobacco tax.

Nebraska’s measure passed with strong support in urban and rural areas, which Larry Dix, executive director of the Nebraska Association of Counties, said stemmed from the relief Medicaid could provide to the state’s struggling rural hospitals. Medicaid coverage for inmates will also relieve the pressure on counties to pay for that care.

The full effect of Idaho’s expansion will depend on a number of factors.

“We know it will be a potential cost saver for counties, we just don’t know by how much yet,” said Seth Grigg, executive director of the Idaho Association of Counties. “There’s uncertainty for what it means for mental health.”

Idaho counties spent $20 million on indigent medical care over fiscal year 2018. Roughly 65,000 people in the state previously made too much for Medicaid coverage and not enough for their own coverage, but Grigg said it was safe to assume many of those people would now be covered.

The problems remain in the $8.6 million counties spent the last fiscal year on mental health. Limited capabilities in Idaho hospitals mean many people subject to involuntary commitments end up treated at facilities that are not eligible for Medicaid reimbursement.

The changing nature of behavioral health care services will affect how Utah’s expansion goes, once it takes effect in April 2019.

“At this point there are differing opinions on the long-term impacts,” said Adam Trupp, executive director of the Utah Association of Counties.

“The initiative included a provision that exempted counties from paying their portion of the cost — the county match — for the expansion population. It also did not include a provision for a ‘carve out’ for behavioral healthcare services,” he said.

Behavioral healthcare appears to be considered mainstream healthcare, he added, which would open the door for the Accountable Care Organizations in Utah, the main Medicaid providers, to take over all care for the expansion population.

“If that occurs, then the county authorities and county providers will have a much more narrow role and, in fact, may have almost no role in the healthcare system,” he said. 

Utah voters also passed a medical marijuana provision, which includes limitations on land use authority of local governments, a prohibition on taxing the products and multiple limitations on law enforcement and prosecution related to possession and production. 

“The Utah Legislature is considering ways to modify the initiative, now law, without violating the intent of it,” Trupp said. “That is proving to be very complicated and some of the solutions offered may be as troublesome as the problem they are seeking to correct.”

California voters defeated Proposition 10, preserving keeping a limit on local governments’ ability to impose rent control and exempting single-family homes and condos from rent control.  They also defeated Proposition 6, which would have repealed the state’s 2017 gas and diesel tax and require a ballot measure to increase those taxes in the future. The California State Association of Counties was also active in opposing Proposition 5, which was defeated. It would have expanded an already existing property tax break for home-owning seniors and people with disabilities, at the cost of over $1 billion per year for local agencies.

Arizona counties cannot enact or increase taxes on services including fitness activities, pet grooming, financial services and healthcare. Counties there can now only tax goods and property.

Florida’s counties cannot abolish constitutional, or row, offices or require them to be elected offices. Voters in the Sunshine State did, however, defeat a $25,000 homestead tax exemption, and approved a permanent cap on property tax assessment increases for non-homestead property. Public officials, including county officials, will be barred from being paid for lobbying work during or six years after their terms in office.

Louisiana’s voters voted to prohibit convicted felons from seeking or holding a public office for five years after completing their sentences.

New Hampshire residents can now take legal action against the state or local government to declare that the government spent, or has approved spending, public funds in violation of a law, ordinance or constitutional provision.