Gov. Bruce Rauner says his administration has put into place a managed-care program to make Illinois' Medicaid program more efficient for taxpayers and improve services for "our most vulnerable families."
But the Republican governor remains critical of the expansion of Medicaid eligibility that took place in 2014 under his Democratic predecessor, Pat Quinn, and continues to be funded in large part through the federal Affordable Care Act.
Rauner, who previously said he would have vetoed the Medicaid expansion, told The State Journal-Register in a recent interview that he is concerned about the impact of the expansion on Illinois taxpayers and disturbed by the trend of more people getting publicly financed health insurance rather than employer-sponsored coverage.
The governor said the expansion "basically has dramatically increased costs for taxpayers, and it has increased the number of folks who are getting health care at the expense of taxpayers rather than through working, and I think that's a wrong trend."
Rauner added, "I think we should get folks out working and getting covered in the workplace and the private marketplace rather than through a government program funded by taxpayers."
Supporters of the ACA and the Medicaid expansion pointed out that 94 percent of the cost of covering the newly eligible Medicaid population -- more than 600,000 adults statewide and more than 12,000 in Sangamon County -- is being covered by the federal government.
Supporters also objected to the tone of Rauner's comments.
"It fits with this very biased, conservative narrative that lazy people are on Medicaid," said Barbara Otto, chief executive officer of Smart Policy Works, a left-leaning not-for-profit organization based in Chicago.
The Medicaid expansion at first was covered 100 percent with federal funds. The ACA calls for federal support for the newly eligible population in Illinois, similar to the more than 30 other states that have adopted the expansion, to drop to 90 percent by 2020 and remain at that level indefinitely.
By contrast, the federal government reimburses Illinois for about 50 percent of costs associated with insuring previously eligible Medicaid enrollees. The previously eligible include minor children and their parents in low-income families, as well as people with disabilities and low-income senior citizens receiving long-term care.
The expansion makes adults eligible for Medicaid if their annual income is less than 138 percent of the federal poverty level, which is $16,753 for an individual, $22,715 for a couple and $28,676 for a family of three.
As a result, 614,430 newly eligible adults across Illinois had enrolled in Medicaid as of May, according to the most recent data available from the Illinois Department of Healthcare and Family Services.
Aides to Rauner didn't respond to follow-up questions from the newspaper about the state's cost for the expansion and other issues raised by the governor's comments about Medicaid.
Rauner aide Elizabeth Tomev said in an email, "While the ACA has major structural flaws, it is the law of the land, and we are doing everything we can to help lower the costs of health care and get Illinoisans the assistance they need."
An analysis by Healthcare and Family Services says it cost an estimated $3.28 billion to pay for the care of the newly eligible parents and childless adults in Illinois' $22 billion Medicaid program in the fiscal year that ended June 30.
A federal match will cover all but $180.4 million of the total cost in Illinois. The state's net cost will be $38 million for Cook County and $142.4 million for the rest of the state.
In the current fiscal year, all but $218 million of the estimated $3.35 billion cost for the newly eligible Medicaid population will be reimbursed to the state by the federal government.
The state's net costs, paid for with general revenue funds and other related funds, are estimated to be $55.7 million for Cook County and $162.2 million for the rest of the state in the fiscal year that ends June 30, 2019.
The expected increases in net state costs are related, in part, to the fact that the federal match will drop to 93 percent on Jan. 1, 2019, according to the HFS analysis.
The Medicaid expansion brought total Medicaid enrollment to 3.14 million, meaning that roughly one in four Illinoisans is covered by the program.
Medicaid expansion advocates said the high reimbursement rate for newly eligible Medicaid recipients allows billions of dollars in federal funds to flow to Illinois for costs that otherwise would be written off by hospitals and other health-care providers for care of the uninsured.
The cost of those unpaid bills in the past may have been shifted to rates paid by insured patients, advocates said.
Even though Medicaid reimbursements often are much lower than what private insurance pays, local hospitals and representatives of the hospital industry statewide supported the Medicaid expansion because they said it didn't make sense to turn down a 90 percent-plus federal match.
A printed list of "talking points" used by the Illinois Health and Hospital Association in support of legislation expanding eligibility said, "Increasing health coverage for adults will enable Illinois to receive significant federal revenues to cover the costs of providing health care to the uninsured -- costs that are currently being paid for by Illinois taxpayers, county and local governments, employers and other institutions."
"A healthier workforce is more productive and will have a positive impact on the state's economy," the association said before the Democratic-controlled General Assembly approved a Medicaid expansion bill with no Republican votes.
The IHA said Illinois' economy was expected to gain $2.6 billion in increase "economic activity" and 19,800 new jobs because of the Medicaid expansion.
Stephanie Altman, director of health-care justice for the left-leaning Sargent Shriver National Center on Poverty Law, said, "The economic engine of the Medicaid expansion more than pays for itself."
It's too soon to measure the actual economic impact, however, Otto said.
A study by Smart Policy Works did show that part-time workers were among those who benefited the most from the Medicaid expansion, she said.
The study said workers in manufacturing who worked 30 to 34 hours a week in Illinois saw a resulting 26 percent increase in coverage.
Otto and Altman said Medicaid coverage doesn't discourage work.
The nonpartisan Kaiser Family Foundation, citing census data, says that almost eight in 10 non-elderly adults with Medicaid coverage nationwide live in working families, and a majority are working themselves.
While Rauner didn't elaborate on his view of the Medicaid expansion, his view seems to fall in line with conservatives such as U.S. Rep. Rodney Davis, R-Taylorville, who has said the overall cost of Medicaid needs to be reined in so states such as Illinois can focus on Medicaid spending for the traditional Medicaid population, which includes children, the elderly and the disabled.
But if the governor wants more people covered by private insurance through their jobs, it's unclear how Rauner wants to convince more employers to offer insurance, Altman said.
Otto said many low-income workers are in jobs that don't offer insurance, or they may work part-time and not be eligible.
Moreover, their employers may be small and exempt from the ACA's mandate that employers offer affordable coverage, she said.
The Smart Policy Works study, conducted by Rob Paral and Associates and based on census data, information from the state and other data, found that more than 325,000 Illinoisans working more than 40 hours per week are enrolled in Medicaid.
"As we consider the economic health of our state, we should remain concerned that such a large number of people still remain eligible for Medicaid despite working full-time or more," the study said. "Instead of assuming people are malingerers, we should ask why a person working full time or more earns so little they still qualify for Medicaid."