At the request of the Louisiana Department of Health, three LSU professors attempted to predict how many people will enroll in Medicaid over the next few years. A draft report completed in June predicted enrollment growth of about 1 percent, which could mean increased costs to taxpayers, but the final version delivered to LDH in August deleted those numbers.
A fiscally conservative think tank has accused the department, whose leaders answer to Gov. John Bel Edwards, of censoring the report and withholding public documents.
“The behavior of LSU and the Department of Health suggests that both continue to hide inconvenient truths from the taxpaying public,” said Chris Jacobs, senior fellow with the Pelican Institute for Public Policy.
Medicaid is a taxpayer-funded health insurance program for low-income residents. Under the federal Affordable Care Act, also known as Obamacare, states could decide to extend Medicaid to people making up to 138 percent of the federal poverty level, which this year means up to $17,236 for an individual or $35,535 for a family of four. The federal government covered the full cost initially and, barring a change in the law, will pay 90 percent of the cost for the expansion population next year and beyond.
Though his predecessor opted against expanding Medicaid under Obamacare, Edwards had Louisiana join the expansion at the beginning of his term in 2016. He has since touted his decision to extend coverage to more than 450,000 working people and cut the state’s uninsured population in half. The change also saves the state money, he says, because the federal reimbursement rate for Medicaid members is higher than for health services for the uninsured.
But the Pelican Institute has been critical of the state's handling of Medicaid expansion and the overall cost of the program, including reports showing more than 1,000 individuals earning six-figure incomes enrolled in Medicaid under Edwards' expansion.
An institute report also noted that tens of thousands of Louisianans who were already enrolled in private health insurance plans left those plans and enrolled in Medicaid, a phenomenon called “crowd out.” Crowd out costs federal and state taxpayers as much as $146 million every year, according to the report.
Now, the institute says, LDH is withholding information about expected Medicaid expansion growth from taxpayers.
But one of the professors involved in the study said the reason for withholding the numbers is simple: They didn’t have much confidence in their projections, especially when it comes to participants in the expanded version of Medicaid. The Louisiana Department of Health says the researchers were working with outdated data that skewed their projections.
“You don’t have a long line of data to work with,” said Jim Richardson, a professor in LSU’s public administration and economics departments and until recently was a member of the state’s Revenue Estimating Conference.
The researchers’ preliminary projections for Medicaid enrollment from 2019 through 2022 were, according to the LSU documents obtained by the Pelican Institute:
• Aged enrollees: projected to increase from 59,692 to 67,257.
• Blind and disabled enrollees: projected to increase from 169,820 to 170,737.
• Child enrollees: projected to increase from 693,833 to 699,035.
• Parent enrollees: projected to increase from 106,369 to 107,143.
• Medicaid expansion enrollees: projected to increase from 567,965 to 571,368.
• Other enrollees: projected to increase from 118,740 to 119,555.
• Total enrollees: projected to increase from 1,658,577 to 1,677,427.
Predicting how many people are likely to be on Medicaid isn’t just an academic exercise. Lawmakers, with an eye toward future budgets, want to know how much the program will grow and how much more it will cost.
As they attempt to predict future enrollment and costs for the program, the Department of Health tapped LSU “to assess the historical pattern of Medicaid enrollment and assist the Department in projecting the number of Medicaid enrollees over time,” department spokeswoman Kelly Zimmerman says. But in the case of Medicaid expansion, there are only a few years of history to draw upon for information, she said.
Also, Richardson said, there isn’t much data about how many people earn 138 percent of the poverty level, and the number of people seeking to enter the program likely would jump if there is a recession. The researchers said expansion enrollment could exceed 571,000 by 2022, but that number is based on full participation by everyone who is eligible, which isn’t what happens in the real world, he said.
According to LDH, the researchers were relying on data that didn’t reflect recent administrative actions, such as the quarterly wage checks made possible by the department’s new enrollment verification system. More recent numbers suggest enrollment is leveling off, though that doesn’t mean costs won’t rise.
At the September meeting of the Medicaid Subcommittee of the Health and Social Services Estimating Conference, LDH presented a report suggesting about 1.5 million people would be in the Medicaid program during the 2022-2023 fiscal year, which is pretty close to the current total. They said the expansion population would be about 437,000, a bit less than today.
Yet they predicted costs would continue to rise from $12.8 billion in the current fiscal year (including about $3.36 billion in state dollars) to $14.5 billion in 2022-2023. The increase partly reflects rising health care expenses, though this year lawmakers made a number of program changes that added $963 million to the Medicaid budget.
In addition, people who are disqualified by the more frequent wage checks enabled by the department's new enrollment verification system tend to be healthier than the average recipient, leaving a Medicaid population that is on average sicker and more expensive to treat, LDH spokesman Bob Johannessen said.
At that September meeting, Pam Diez, deputy undersecretary for the health department, said “no clear pattern” had yet emerged that would allow department staff to be confident in their enrollment projections. Diez said the department would continue to work with the LSU researchers to firm up the numbers, and the committee decided to wait until later in the year before adopting an official projection.
LDH did not release the LSU enrollment report to the public; officials say it was an internal working document meant to inform their projections. But the Pelican Institute's Jacobs says the decision is part of a pattern of secrecy around the state’s Medicaid program.
Jacobs points out that, according to the work order, LSU was paid in part for a “slide presentation for public bodies,” suggesting the work initially was intended for public release.
“It seems very dubious for the Department of Health to spend a total of $71,120 in taxpayer funds on an ‘enrollment projection’ study that includes no actual enrollment projections,” he said.
Jacobs said he has been trying to obtain documents through public records requests that he believes would shed light on, among other questions, why the enrollment projections in the initial draft were not included in the final report. As recently as Oct. 8, he said, the department claimed it had no documents related to the study.
The Pelican Institute also has criticized LSU studies the health department commissioned last year purporting to show the economic impact of Medicaid expansion. Jacobs says the LSU paper over-counted the federal dollars and jobs associated with Medicaid expansion by failing to subtract people who forfeited federal subsidies that could have been used to buy exchange policies when they joined Medicaid after expansion.
Researchers eventually acknowledged they overstated the impact in a follow-up report but never publicly retracted the first study, Jacobs said. LDH says it has publicly posted the economic studies and answered every question it has received about them.
As for the enrollment study, the department did not write or edit the report but did provide feedback, and "observed that the enrollment projections relied on base data that predated certain administrative changes which had a significant downward effect on enrollment," such as quarterly wage checks to determine eligibility, Johannessen said.
"LSU fulfilled the contract based on the data available to them at the time of their study," he said. "Had the more recent data been available to the LSU researchers for use in the timely production of contract deliverables, however, LDH expects the projections would have been consistent with current knowledge."
The contract included a slide deck for a public presentation as a deliverable, but since it reflected outdated information, the department chose not to present it, he said.
Public records requests often are very broad, not well defined or vague, which leads to some back and forth to clarify the request, Johannessen notes. He said the number of records requests to LDH has basically doubled to about 66 per month since the department established an online request portal early this year.
“The Department is responding to all public records requests within the appropriate legal timelines,” Johannessen said. “This includes all of the requests from the Pelican Institute.”
Jacobs countered that it has received information from LSU, including email exchanges between university officials and health department staff, that the health department has not disclosed through public records requests.
"LSU disclosed it to us; the Department of Health said they had no responsive documents," Jacobs said.