Texas et al v. United States of America et al
Filing
91
RESPONSE filed by District of Columbia, State of California, State of Connecticut, State of Delaware, State of Hawaii, State of Illinois, State of Kentucky, State of Massachusetts, State of Minnesota, State of New Jersey, State of New York, State of North Carolina, State of Oregon, State of Rhode Island, State of Vermont, State of Virginia, State of Washington re: 39 MOTION for Injunction (Attachments: # 1 Appendix of Supporting Evidence - Part 1, # 2 Appendix of Supporting Evidence - Part 2, # 3 Proposed Order) (Palma, Neli)
00237
00238
00239
00240
00241
00242
00243
00244
00245
00246
00247
00248
00249
00250
00251
00252
00253
00254
00255
00256
00257
00258
00259
00260
00261
00262
00263
00264
00265
00266
00267
00268
00269
00270
00271
00272
00273
00274
00275
00276
00277
00278
00279
00280
00281
00282
00283
00284
00285
00286
00287
00288
00289
00290
00291
00292
00293
00294
00295
00296
00297
00298
00299
00300
00301
00302
00303
00304
00305
00306
00307
00308
00309
00310
00311
00312
00313
00314
00315
00316
00317
00318
00319
00320
00321
00322
00323
00324
00325
00326
00327
00328
00329
00330
00331
00332
00333
00334
00335
00336
00337
00338
00339
00340
00341
00342
00343
00344
00345
Table 3
State Adoption of Optional Medicaid and CHIP Coverage for Children, January 2018
Coverage for Dependents of
State
State Employees in CHIP
(Total = 36)
Total
Alabama
Alaska
Arizona
Lawfully-Residing Immigrants
Covered without 5-Year Wait
5
3
2
Medicaid
18
Y
N/A (M-CHIP)
33
CHIP
(Total = 36)
Y
Y
Y
Y
Y
Y
N/A (M-CHIP)
Y
Y
Y
N/A (M-CHIP)
Y
Y
N/A (M-CHIP)
Y
Y
N/A (M-CHIP)
Y
Y
N/A (M-CHIP)
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N/A (M-CHIP)
Y
N/A (M-CHIP)
N/A (M-CHIP)
Y
Y
Y
N/A (M-CHIP)
Y
Y
Y
Y
N/A (M-CHIP)
Y
N/A (M-CHIP)
Y
Y
Delaware7
District of Columbia
Florida
Georgia
Hawaii
Idaho
6
6
Illinois
Indiana
8
Iowa
Kansas
Kentucky
Y
Y
Louisiana
12
N/A (M-CHIP)
Y
6
California
Colorado
Connecticut
Provides Medicaid Coverage to
Former Foster Youth up to Age 26
from Other States4
22
N/A (M-CHIP)
Y
Y
Arkansas
Y
Y
Y
Y
9
10
Y
N/A (M-CHIP)
Maine
Maryland
6
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
9
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
N/A (M-CHIP)
N/A (M-CHIP)
Y
Y
N/A (M-CHIP)
Y
N/A (M-CHIP)
N/A (M-CHIP)
6,.
New York 9
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
1, 2
Y
N/A (M-CHIP)
N/A (M-CHIP)
Y
6
Pennsylvania
Rhode Island
11
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
12
Y
N/A (M-CHIP)
N/A (M-CHIP)
N/A (M-CHIP)
N/A (M-CHIP)
Y
Y
Y
Y
Y
N/A (M-CHIP)
N/A (M-CHIP)
Y
Y
Y
Y
Y
N/A (M-CHIP)
Y
6
Washington
West Virginia
Wisconsin
Wyoming
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N/A (M-CHIP)
Y
Y
Y
Y
Y
Y
Y
SOURCE: Based on a national survey conducted by the Kaiser Family Foundation with the Georgetown University Center for Children and Families,
2018.
Table presents rules in effect as of January 1, 2018.
Medicaid and CHIP Eligibility, Enrollment, Renewal, and Cost Sharing Policies as of January 2018
00346
29
Table 12
Presumptive Eligibility in Medicaid and CHIP, January 20181
Pregnant Women
Children
State
Total
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas3
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico4
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
5
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
2
Medicaid
20
CHIP
(Total =36)
11
2
Medicaid
30
N/A (M-CHIP)
Y
Y
Y
Y
Y
N/A (M-CHIP)
Y
Y
Y
Y
Y
N/A (M-CHIP)
Y
Y
Y
Y
Y
Y
N/A (M-CHIP)
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N/A (M-CHIP)
Y
N/A (M-CHIP)
N/A (M-CHIP)
Y
Y
Y
Y
Y
N/A (M-CHIP)
Y
Y
Y
N/A (M-CHIP)
Y
N/A (M-CHIP)
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N/A (M-CHIP)
N/A (M-CHIP)
Y
Y
N/A (M-CHIP)
N/A (M-CHIP)
Y
Y
Y
Y
N/A (M-CHIP)
CHIP
(Total = 5)
3
N/A
N/A
N/A
N/A
N/A
Y
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Y
N/A
N/A
N/A
N/A
Y
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Parents
9
Adults2
(Total = 33)
6
N/A
Family Planning
Expansion2
(Total = 29)
6
Former
Foster
Youth
10
N/A
N/A
N/A
Y
N/A
Y
N/A
N/A
Y
N/A
N/A
Y
N/A
Y
Y
Y
N/A
N/A
N/A
Y
N/A
N/A
Y
Y
Y
N/A
N/A
N/A
Y
Y
Y
Y
N/A
N/A
Y
N/A
Y
Y
Y
Y
N/A
N/A
Y
N/A
Y
N/A
Y
N/A
N/A
N/A
N/A
N/A
N/A
Y
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Y
N/A
N/A
N/A
N/A
N/A
Y
Y
Y
Y
Y
Y
N/A
N/A
N/A
N/A
Y
Y
Y
N/A
Y
Y
N/A
Y
SOURCE: Based on a national survey conducted by the Kaiser Family Foundation with the Georgetown University Center for Children and
Families, 2018.
Table presents rules in effect as of January 1, 2018.
Medicaid and CHIP Eligibility, Enrollment, Renewal, and Cost Sharing Policies as of January 2018
00347
49
00348
00349
00350
00351
00352
00353
00354
00355
00356
00357
00358
00359
00360
00361
00362
00363
00364
00365
00366
00367
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF TEXAS
FORT WORTH DIVISION
2
3
4
5
6
7
TEXAS, WISCONSIN, ALABAMA, ARKANSAS ,
ARIZONA, FLORIDA, GEORGIA, INDIANA,
KANSAS, LOUISIANA, PAUL LePAGE,
Governor of Maine, Governor Phil Bryant of the
State of MISSISSIPPI, MISSOURI, NEBRASKA,
NORTH DAKOTA, SOUTH CAROLINA, SOUTH
DA KOTA, TENNESSEE, UTAH, WEST
VIRGINIA, NEILL HURLEY and JOHN NANTZ,
8
Plaintiffs,
Civil Action No. 4: 18-cv-00167-0
9
10
11
12
13
14
UNITED STATES OF AMERICA, UNITED
STATES DEPARTMENT OF HEALTH AND
HUMAN SERVICES, ALEX AZAR, in his
Official Capacity as SECRETARY OF HEALTH
AND HUMAN SERVICES, UNITED STATES
INTERNAL REVENUE SERVICE, and DAVID
J. KAUTTER, in his Official Capacity as Acting
COMMISSIONER OF INTERNAL REVENUE,
Defendants.
15
16
17
18
19
CALIFORNIA, CONNECTICUT, DISTRICT OF
COLUMBIA, DELAWARE, HAWAll, ILLINOIS,
KENTUCKY, MASSACHUSETTS, MINNESOTA
by and through its Department of Commerce, NEW
JERSEY, NEW YORK, NORTH CAROLINA,
OREGON, RHODE ISLAND, VERMONT,
VIRGINIA and WASHINGTON,
20
Intervenors-Defendants.
21
22
DECLARATION OF JUDY MOHR PETERSON, IN SUPPORT OF INTERVENORSDEFENDANTS' OPPOSITION TO APPLICATION FOR PRELIMINARY INJUNCTION
23
24
25
26
I, Judy Mohr Peterson, declare:
1)
I serve as the Medicaid Director for the State of Hawaii. I have been in this role
since July 2015. Prior to that, I served as the Medicaid Director for the Oregon Health
27
Authority in the State of Oregon (2009-June 2015).
28
Deel. o f Judy Mohr Peterson in Support of lntervenors-Defcndants' Opposition to Application for Preliminary
Inj unction (4: I 8-cv-00 I 67-0 )
00368
2)
Med-QUEST, Department of Human Services, is the single state Medicaid Agency
2
for the State of Hawaii and implements Hawaii's Medicaid program. I am the administrator of
3
the Med-QUEST Division.
4
5
This declaration is submitted in support of the Intervenor-States' Opposition to
3)
Plaintiffs' Motion for Preliminary Injunction.
6
Granting a preliminary injunction would result in significant costs and
4)
7
8
9
injuries to the State Medicaid Agency and to state residents. Based on my knowledge and
experience, dismantling the Affordable Care Act would result in a loss of benefits and
10
services and federal investments to support Med-QUEST and the 360,000 beneficiaries
II
served. In addition, it would cause severe harm to the state of Hawaii, to its residents, and to
12
its economy. Hawaii would experience harm and increased costs from the dismantling of the
13
state's administrative structure and apparatus, created in compliance with, and to work in
14
conjunction with, the Affordable Care Act (ACA) in the following ways:
15
16
•
Hawaii's current eligibility system, KOLEA, is programmed to determine
17
Medicaid eligibility using ACA prescribed eligibility determination
18
methodologies. Changing the eligibility determination methodologies would
19
require extensive computer operating system modifications at an estimated cost of
20
$4,000,000.00 ($3,000,000 federal funds; $1,000,000 state funds);
21
•
Notices regarding changes to eligibility would have to be developed and sent out
22
to affected individuals. Approximately $1,000,000.00 (750,000.00 federal funds;
23
24
$250,000.00 state funds) would be needed for the development of new notices and
25
approximately $350,000 ($174,000.00 federal funds; $175,000.00 state funds)
26
would be needed for the production and mailing costs;
27
•
The State of Hawaii would incur an estimated $250,000 ($125,000.00 federal
28
2
Deel. of Judy Mohr Peterson in Support of Intervenors-Defendants' Opposition to Application for Preliminary
Injunction (4:18-cv-00167-0 )
00369
funds; $ 125,000.00 state funds) in costs related to training staff on new policies
and procedures;
2
3
•
4
A change in eligibility determination methodologies would cause major
interruption and delays in determination of eligibility benefits for applicants and
5
eligibility redetermination of beneficiaries (approximately 305,000 individuals);
6
5) Hawaii could lose billions of dollars provided through the Affordable Care Act
7
8
9
•
Specifically, Hawaii has received $2.1 billion via the Medicaid expansion.
•
The Public Health and Prevention Fund provides approximately $8 million
10
annually to Hawaii, which the state uses to manage and administer data systems
11
like the Behavioral Risk Factor Surveillance System and Hawaii's Surveillance
12
and Disease Outbreak Management System. The funding is also used to recognize
13
disease trends, incidence, and impact, and to develop preventive and response
1
4
measures as needed. Health care services to those with HIV or Zika are also
15
affected.
16
17
18
6) Thousands of Hawaii residents could lose access to affordable coverage
•
19
Overall the number of individuals with insurance has increased. In Hawaii, the
rate of uninsured was 5% in 2016, the most recent figure available. The ACA
20
expanded coverage through two key mechanisms: Medicaid expansion for those
21
individuals with the lowest incomes, and federal health subsidies to purchase
22
coverage in new health insurance Exchanges for those individuals with moderate
23
mcomes.
24
25
26
27
•
Medicaid is an important source of healthcare insurance coverage and has resulted
in coverage gains and reduction in the uninsured rate, both among the low-income
population and within other vulnerable populations. As a result of Medicaid
28
'.I
Deel. o f Judy Mohr Pe terson in Support of Intervenors-Defendants' Oppositio n to Application for Preliminary
Inj unc tion (4: 18-cv-OO 167-0 )
00370
expansion in Hawaii, 117,000 people have coverage -- approximately one-third of
2
our total of 360,000 on Medicaid -- and the state has experienced a reduction in the
3
uninsured rate. This 117,000 figure includes individuals who became eligible for
4
Medicaid under Hawaii's early (pre-2013) expansion as well as the 33,000 who
5
became eligible under the further expansion implemented in October 2013.
6
Without the ACA, all of these people would lose coverage. About 30% of the
7
expansion group suffers from mental illness, 4% of them with severe mental
8
9
illness; 1 in 4 have diabetes; 30% have asthma while 1 in 8 has chronic obstructive
10
disease; and over one third struggle with some sort of substance use issue. Lack of
11
health insurance would likely lead to an exacerbation of the health conditions,
12
negatively impacting their health. On average, Hawaii spends about $510 monthly
13
for each Medicaid expansion person or about $6,120 annually. We receive
14
enhanced federal match for this population.
15
16
•
Using alternate eligibility determination methodologies would result in many
17
beneficiaries losing eligibility which in turn would cause loss of revenue for
18
providers and health plans, and reduced federal matching dollars;
19
•
20
An injunction of the ACA would impact all of the non aged, blind, or disabled
groups, affecting approximately 80% of the total Medicaid population of Hawaii,
21
which currently stands at 362,464 beneficiaries (as of March, 2018);
22
23
•
Hawaii's low-income population would lose coverage if or until CMS approves an
24
1115 waiver amendment to cover the low-income population. However, Hawaii
25
would have to demonstrate that coverage of this population would be "budget
26
neutral", in other words, that it would not cost more to the federal government than
27
not covering them. A budget neutrality test would be extremely diffic ult to pass
28
4
Deel. of Judy Mohr Peterson in Suppo rt of Intervenors-De fondants' Oppositio n to Applicatio n for Preliminary
Inj unctio n (4: (8.cv-00167 -0 )
00371
making it more likely that the entire ACA adult expansion population would lose
2
their eligibility if they did not qualify for any other program. Even if Hawaii were
3
able to reinstate this population by way of an 1115 waiver, Hawaii would Jose the
4
enhanced match for that population.
5
•
The Exchange is an important reform made by the ACA. In Hawaii in 2017,
6
16,711 people were covered on the Marketplace, with 13,728 eligible for APTC
7
subsidies.
8
9
7) The loss of programs that were expanded under the ACA would lead to a
10
decrease in opportunities to access home and community based services.
11
•
12
Medicaid Money Follows the Person Demonstration: in 2015 Hawaii received
over $2 million under this program. It has helped move 584 people living in
13
institutions into home or community based settings.
14
15
16
8) All of the foregoing injuries would occur if the Plaintiffs' motion for preliminary
injunction were granted.
17
18
I declare under penalty of perjury that the foregoing is true and correct and of my own
19
personal knowledge.
20
Executed on June Q..5., 2018, in Honolulu, Hawaii.
21
22
23
J dy ohr Peterson
Administrator, Med-QUEST Division
Department of Huma n Services
State of Hawaii
24
25
26
27
28
5
Deel. of Judy Mohr Peterso n in Support of Intervenors-Dcfcndants' O ppositio n lO Application for Preliminary
Inj unction (4: I 8-cv-00 167-0)
00372
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF TEXAS
FORT WORTH DIVISION
TEXAS, WISCONSIN, ALABAMA, ARKANSAS,
ARIZONA, FLORIDA, GEORGIA, INDIANA,
KANSAS, LOUISIANA, PAUL LePAGE,
Governor of Maine, Governor Phil Bryant of the
State of MISSISSIPPI, MISSOURI, NEBRASKA,
NORTH DAKOTA, SOUTH CAROLINA, SOUTH
DAKOTA, TENNESSEE, UT AH, WEST
VIRGINIA, NEILL HURLEY and JOHN NANTZ,
Plaintiffs,
Civil Action No. 4:18-cv-00167-0
v.
UNITED STATES OF AMERICA, UNITED
STATES DEPARTMENT OF HEALTH AND
HUMAN SERVICES, ALEX AZAR, in his Official
Capacity as SECRETARY OF HEALTH AND
HUMAN SERVICES, UNITED STATES
INTERNAL REVENUE SERVICE, and DAVID J.
KAUTTER, in his Official Capacity as Acting
COMMISSIONER OF INTERNAL REVENUE,
Defendants.
CALIFORNIA, CONNECTICUT, DISTRICT OF
COLUMBIA, DELAWARE, HAWAll, ILLINOIS,
KENTUCKY, MASSACHUSETTS, MINNESOTA
by and through its Department of Commerce, NEW
JERSEY, NEW YORK, NORTH CAROLINA,
OREGON, RHODE ISLAND, VERMONT,
VIRGINIA and WASHINGTON,
Intervenors-Defendants.
DECLARATION OF CLAUDIA SCHLOSBERG IN SUPPORT OF INTERVENORSDEFENDANTS' OPPOSITION TO APPLICATION FOR PRELIMINARY
INJUNCTION
Deel. of Claudia Schlosberg in Support ofli1tervenor -Defendants Opposirion to Motion for Preliminary Injunction
(4:18-cv-00167-0)
00373
I, Claudia Schlosberg, declare:
1.
This declaration is submitted in support of the Intervenors-Defendants' Opposition
to the Motion to Intervene. Based on my knowledge and experience, dismantling the Affordable
Care Act would cause severe harm to the District of Columbia, to its residents and to its
economy. In addition to loss of benefits and services and federal investments to support the
District of Columbia's healthcare system, dismantling or suspending implementation of the
Affordable Care Act would cause severe harm to the District of Columbia, to its residents and to
its economy. The District of Columbia would experience harm and increased costs from the
dismantling of the District's administrative structure and apparatus, created in compliance with,
and to work in conjunction with, the Affordable Care Act.
2.
I am the Senior Deputy and State Medicaid Director for the Department of Health
Care Finance (DHCF) for Washington, D.C. I am responsible for the effective management of
the Medicaid, CHIP and Alliance Health Insurance Programs. Together, these programs provide
DHCF health insurance coverage to over 270,000 low income residents of the District of
Columbia. I currently oversee policy development, eligibility, fee-for-service and managed care
service delivery, program operations, program integrity, long-term care and implementation of
health care reform and innovation. Previously, I served as DHCF's Director of the Health Care
Policy and Research Administration. I have been employed at DHCF since August 2011 and
have over 30 years of experience in health care policy, program administration and regulatory
and legislative affairs pertaining to publicly-financed health care programs.
3.
DHCF is the single state agency for the administration of Medicaid in the District
of Columbia (the District). DHCF is accountable to the United States Centers for Medicare and
2
Deel. of Claudia Schlosberg in Support oflntervenors-Defendants Opposition to Motion for Preliminary Injunction
(4: l 8-cv-00167-0)
00374
Medicaid Services (CMS), the federal agency responsible for administration and oversight of the
Medicaid program under Titles IXX and XX.I of the Social Security Act, as amended by the
Patient Protection and Affordable Care Act (the ACA) and accompanying regulations. Under the
Affordable Care Act, the District has made significant gains with regard to healthcare funding,
Medicaid coverage, access to care, and the quality of health care services delivered, as
highlighted below:
4. The Affordable Care Act directs significant funding to the District of Columbia:
•
Specifically, the District of Columbia has received $2.05 billion in federal reimbursement for
Medicaid expansion; $53 million in grants provided under the Public Health and Prevention
Fund from 2010 to 2016 1; $4.2 million in grants and funding from the Center for Medicare
and Medicaid Innovation; and $6.8 million in federal Medicaid reimbursement to provide
Health Home services authorized under Section 2703 of the ACA.
5.
•
The Affordable Care Act increased access to affordable coverage.
The ACA expanded coverage through two key mechanism: Medicaid expansion for those
individuals with the lowest incomes, and federal health subsidies to purchase coverage in
new health insurance exchanges for those individuals with moderate incomes.
•
From 2010 to 2016, the District's overall uninsured rate fell 44%, from 7.8% to 4%, and the
uninsured rate for the lowest-income individuals (0-199 percent of the federal poverty level
(FPL) covered under the District's Medicaid expansion program fell 42 percent, from 13.5
percent to 7.8 percent. This increase in coverage has directly resulted from the ACA' s new
affordable coverage options and the Medicaid expansion, combined with new support for
outreach from assisters and one-stop streamlined enrollment through the Health Benefits
Exchange portal, DC Healthlink, all funded and directed under the ACA.
1 Prevention and Public Health Fund Detailed Information - Trust for America's Health (Trust for
America's Health, August 2017) http://healthyamericans.org/report/134/.
3
Deel. of Claudia Schlosberg in Support oflntervenors-Defendants Opposition to Motion for Preliminary Injunction
(4 : 18-cv-OO 167-0 )
00375
•
Medicaid is an important source of healthcare insurance coverage and has resulted in
significant coverage gains and reduction in the uninsured rate, both among the low-income
population and within other vulnerable populations. Nearly 60 percent of the 321,518
individuals served by the District Health Benefits Exchange from when the Exchange opened
in October 2013 through April 2017 were Medicaid beneficiaries. In FY 2017, the District
Medicaid program provided coverage to approximately 40 percent of all District residents.
Total average monthly Medicaid enrollment has grown 54 percent since the District
expanded Medicaid, from nearly 170,000 in 2010 to 262,250 in 2017 and most of these
coverage gains have been from the Medicaid expansion eligibility group. The District's
generous levels of coverage for children under Medicaid and a CHIP-funded Medicaid
expansion have also contributed to strong coverage rates overall. The District's rate of
insurance coverage for children (97%) and its participation rate in public coverage programs
(98.6%) are among the highest in the nation. In FY 2017, 93,184 childless Medicaid
expansion adults and 89,491 children were enrolled in the District's Medicaid program, with
each group comprising one-third of total Medicaid enrollment.
•
The ACA has led to increased access to affordable care in the District as well as improved
financial security for individuals who previously experienced trouble paying medical bills.
According to the Commonwealth Fund, from 2013 to 2016, there was approximately a 20
percent decrease in the number adults in the District who went without care due to cost and a
similar decrease in the number of individuals with high out-of-pocket medical spending. 2
From 2013 to 2016, there was a 40 percent decrease in the number of at risk adults who were
without a routine doctor visit in the past two years.
6.
•
The ACA has had a positive economic benefit for the District.
The District has realized budget savings and revenue gains under the ACA.
2 Susan Hayes, et al., What 's at Stake: States' Progress on Health Coverage and Access to Care, 20132016 (The Commonwealth Fund, Dec. 2017) http://www.commonwealthfund.org/publications/issuebriefs/201 7/dee/states-progress-health-coverage-and-access.
4
Deel. of Claudia Schlosberg in Support oflntervenors-Defendants Opposition to Motion for Preliminary Injunction
(4: 18-cv-OO 167-0)
00376
•
As an estimate of the substantial economic gains the District has experienced from coverage
expansions and other provisions of the ACA, the Economic Policy Institute estimated that the
District would lose between an estimated $100 and $146 million in federal health care
spending per year in the event of ACA repeal. 3
•
The District also gained financially by having the federal government fund programs that
were previously locally funded. Before the ACA was enacted, the District operated the DC
Healthcare Alliance Program (Alliance), a 100 percent locally-funded program designed to .
provide medical assistance to low-income District residents ineligible for Medicaid or
Medicare. With the Medicaid expansion to childless adults in 2010, the District was able to
transition over 30,000 individuals who previously received coverage under the Alliance
program to the new Medicaid expansion, thereby shifting the financial burden for coverage
for these individuals from local to federal funds, which were covered at 100% federal
medical assistance percentage in the first few years. In 2014 and 2015, the District saved
approximately $82 million in averted local spending as a result of receiving federal matching
funds for these individuals who previously were enrolled in the District's Alliance program. 4
•
By covering previously uninsured and underinsured individuals, the District's Medicaid
expansion also enabled the District to save in spending for locally-funded behavioral health
service programs that previously provided services to most of the more than 93,000
individuals now covered under the childless adult expansion.
•
District hospital uncompensated care costs declined by 60% from $250,000 in 2010 to
$100,000 in 2015 as the District's Medicaid expansion and ACA coverage expansion was
implemented. 5
3 Josh Bivens, Repealing the Aff rdable Care Act Would Cost Jobs in Every State (Economic Policy
o
Institute, (Jan. 31, 2017) https://www.epi.org/files/pdf/120447.pdf.
4 Deborah Bachrach, et al., States Expanding Medicaid See Significant Budget Savings and Revenue Gains,
(RWJF State Health Reform Assistance Network, March 2016),
https://www.rwjf.org/contcnt/dam/farm/report. /issue briefs/20 I 6/rwjf419097
5 Uncompensated Care Summary, 20 I 0-2015, DC Department of Health, State Health Planning
Development Administration,
ed
htlps://hbx.dc.gov/ ites/defaul files/dc/sites/hbx/event conte11Uauachments/U11compensated care upda1 IO I 1
(continued ... )
5
Deel. of Claudia Schlosberg in Support of lntervenors-Defendants Opposition to Motion for Preliminary Injunction
(4: 18-cv-00167-0)
00377
•
Researchers have estimated that the District has also experienced strong job and economic
growth as a result of the ACA and could risk losing an estimated 1,400 jobs in year one and
over 6,000 jobs over the next eight years if the ACA or its Medicaid expansion is repealed. 6
7.
The ACA expanded Medicaid programs to provide States with increased
opportunities to increase access to home and community based services.
•
The ACA extended and expanded the Money Follows the Person (MFP) demonstration
program. The District's MFP rebalancing demonstration project is a pathway to independent
living for individuals who have physical disabilities, and with intellectual and developmental
disabilities. MFP functions through the District's two home and community-based (HCBS)
waiver programs operated by DHCF and the District's Department on Disability Services.
The federal grant program provides support to the District in order to shift Medicaid
spending on long-term care away from a facility based system to one that offers services and
supports in HCBS by allowing individuals receiving to choose where to receive their
services. The District has received a cumulative award of $18.5 million under the
demonstration program attributable to the ACA, from 2012 until the first quarter of FY 2018.
•
In addition to covering HCBS costs for these individuals at an enhanced federal match rate
for up to 365 days after discharge, the MFP grant provided important support to build the
District's capacity to provide transition coordination, housing identification, and intensive
case management services for people moving from facility-based care to the community.
From its inception in 2008 to 2014, MFP has transitioned an average of 29 beneficiaries per
year from facilities to HCBS. From 2015 to 2017, MFP transitioned approximately 38
beneficiaries per year. In 2017, MFP funding helped transition 38 beneficiaries to the
community and another 40 beneficiaries received HCBS and support services funded through
the demonstration.
15.pdf
6
Bivens, supra note 3.
6
Deel. of Claudia Schlosberg in Support of Intervenors-Defendants Opposition to Motion for Preliminary Injunction
(4: l 8-cv-00167-0)
00378
8.
The ACA has allowed the District to test and implement reforms to healthcare
delivery systems that support State policy priorities of increasing efficiency and quality of
care.
Under CMMI State Innovation Model (SIM) Round Two, DHCF spent over $720,000 of a
Design Award to develop a State Health Innovation Plan (SHIP). The SHIP set forth the
District's plan to: reform care delivery by implementing an integrated system capable of
delivery value-based care; reform reimbursement by designing a payment structure that
aligns provider reimbursement with improvement in health outcomes; and improve
population health through integration of community linkages and care redesign. As the
District works toward realization of the goals set forth in the SHIP DHCF has implemented
several programs and initiatives. A few of these initiatives are set forth below.
Health Homes
On January 1, 2016, DHCF, in coordination with the District Department of Behavioral
Health, launched My DC Health Home, a new Health Home benefit (authorized under
Section 2703 of the ACA) for Medicaid beneficiaries with serious and persistent mental
health care needs. The health home provider coordinates a person's full array of health and
social service needs- including primary and hospital health services; mental health care,
substance abuse care and long-term care services and supports. My DC Health Home
currently provides services to over 1,700 District Medicaid beneficiaries. The goal of the
program is to serve unmet need in this vulnerable population an in the process reduce
avoidable health care costs, specifically preventable hospital admissions, readmissions, and
avoidable emergency room visits for the individuals with serious and persistent mental
illnesses enrolled My DC Health Home.
On July 1, 2017, DHCF launched My Health GPS, a second Health Home program for
Medicaid beneficiaries with multiple chronic conditions. Under this initiative,
interdisciplinary teams embedded in the primary care setting serve as the central point for
7
Deel. of Claudia Schlosberg in Support of Intervenors-Defendants Opposition to Motion for Preliminary Injunction
(4 : 18-cv-00167-0)
00379
integrating and coordinating the full array of eligible beneficiaries' primary, acute,
behavioral health, and long-term services and supports to improve health outcomes and
reduce avoidable and preventable hospital admissions and ER visits. My Health GPS
currently serves over 3,500 District Medicaid beneficiaries.
Payment Reform Initiatives
DHCF has also implemented a number of payment reforms for providers in an effort to move
incrementally toward the goal of value-based purchasing. Payment reform initiatives include:
a pay-for-performance program for Federally-Qualified Health Centers; a quality
improvement incentive program for nursing facilities; and two quality improvement incentive
programs for My Health GPS providers.
9.
All of the foregoing benefits of the Affordable Care Act would be removed if the
Plaintiffs' preliminary injunction were granted.
I declare under penalty of perjury that the foregoing is true and correct and of my own
personal knowledge.
Executed on June 6, 2018, in Washington, District o
8
Deel. of Claudia Schlosberg in Support oflntervenors-Defendants Opposition to Motion for Preliminary Injunction
(4: 18-cv-00167-0)
00380
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF TEXAS
FORT WORTH DIVISION
TEXAS, WISCONSIN, ALABAMA, ARKANSAS,
ARIZONA, FLORIDA, GEORGIA, INDIANA,
KANSAS, LOUISIANA, PAUL LePAGE,
Governor of Maine, Governor Phil Bryant of the
State of MISSISSIPPI, MISSOURI, NEBRASKA,
NORTH DAKOTA, SOUTH CAROLINA, SOUTH
DAKOTA, TENNESSEE, UTAH, WEST
VIRGINIA, NEILL HURLEY and JOHN NANTZ,
Plaintiffs,
Civil Action No. 4:18-cv-00167-O
v.
UNITED STATES OF AMERICA, UNITED
STATES DEPARTMENT OF HEALTH AND
HUMAN SERVICES, ALEX AZAR, in his
Official Capacity as SECRETARY OF HEALTH
AND HUMAN SERVICES, UNITED STATES
INTERNAL REVENUE SERVICE, and DAVID
J. KAUTTER, in his Official Capacity as Acting
COMMISSIONER OF INTERNAL REVENUE,
Defendants.
CALIFORNIA, CONNECTICUT, DISTRICT OF
COLUMBIA, DELAWARE, HAWAII, ILLINOIS,
KENTUCKY, MASSACHUSETTS, MINNESOTA
by and through its Department of Commerce, NEW
JERSEY, NEW YORK, NORTH CAROLINA,
OREGON, RHODE ISLAND, VERMONT,
VIRGINIA and WASHINGTON,
Intervenors-Defendants.
DECLARATION OF RYAN SMITH IN SUPPORT OF INTERVENORS-DEFENDANTS’
OPPOSITION TO APPLICATION FOR PRELIMINARY INJUNCTION
00381
I, Ryan Smith, declare:
1.
I am 28 years old and a resident of Chicago, Illinois. I am currently employed as a
legal assistant and will be attending law school in fall 2018.
2.
In the summer of 2013 my physician diagnosed me with two separate mental
illnesses: generalized anxiety disorder and panic disorder. I made the decision to go
on a daily medication to manage my mental illness. At the time, my employer
provided health insurance that made the cost of my medications affordable. Prior to
medication, I was experiencing daily panic attacks. They were debilitating in that
they lasted for hours, left me unable to sleep at night, and interfered with my normal
work routine. The medication I was prescribed, Sertraline, helped prevent my panic
attacks. I went from having one to two every day to having none at all.
3.
In the fall of 2014, I lost my job and with it, my health benefits. Fortunately, my
then-home of Michigan had established a healthcare exchange, and I was able to
purchase health insurance on the exchange that was affordable, thanks in part to
subsidies provided by the ACA. This helped keep the cost of my medication and
doctor's visits at an affordable level. Without insurance, my prescriptions would have
cost hundreds of dollars a month, which I could not afford while I was unemployed.
4.
If I had not been able to afford my medication, searching for a job would have been
exceptionally difficult, and my unemployment would have been prolonged. With my
medication, and the affordable insurance I had through the healthcare exchange, I
was able to actively search for employment. Access to mental healthcare is as critical
as access to physical healthcare, and without the Affordable Care Act, my experience
with unemployment might have been substantially worse.
00382
5.
Even though I am no longer covered through a plan purchased through the
marketplace, I continue to utilize mental health services, and the protections offered
under the Affordable Care Act remain critical. I know that whatever plan I enroll in
will include mental health services as an essential health benefit, that mental health
treatments will be in parity with other kinds of health services, and I will never be
discriminated against for a pre-existing condition.
6.
I support the Intervenor-Defendants' defense of the ACA. Elimination of the ACA
would hurt me and my family.
I declare under penalty of perjury that the foregoing is true and correct and of my own
personal knowledge.
Executed on June 1, 2018, in Chicago, Illinois.
Rya~ Smith
00383
1
2
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF TEXAS
FORT WORTH DIVISION
3
4
9
TEXAS, WISCONSIN, ALABAMA, ARKANSAS,
ARIZONA, FLORIDA, GEORGIA,
INDIANA, KANSAS, LOUISIANA,
PAUL LePAGE, Governor of Maine,
Governor Phil Bryant of the State of
MISSISSIPPI, MISSOURI,
NEBRASKA, NORTH DAKOTA,
SOUTH CAROLINA, SOUTH
DAKOTA, TENNESSEE, UT AH,
WEST VIRGINIA, NEILL
HURLEY and JOHN NANTZ,
10
Plaintiffs,
5
6
7
8
Civil Action No. 4:18-cv-00167-0
11
12
13
14
15
\.TES OF AMERICA, UNITED STATES
DEPARTMENT OF HEALTH AND HUMAN
SERVICES, ALEX AZAR, in his Official
Capacity as SECRETARY OF HEALTH AND
HUMAN SERVICES, UNITED STATES
INTERNAL REVENUE SERVICE, and DAVID
J. KAUTTER, in his Official Capacity as Acting
COMMISSIONER OF INTERNAL REVENUE,
16
Defendants.
17
18
19
20
21
22
23
24
25
26
CALIFORNIA, CONNECTICUT, DISTRICT OF
COLUMBIA, DELAWARE,
HAWAll, ILLINOIS, KENTUCKY,
MASSACHUSETTS, MINNESOTA
by and through its Department of
Commerce, NEW JERSEY, NEW
YORK, NORTH CAROLINA,
OREGON, RHODE ISLAND,
VERMONT, VIRGINIA and
WASHINGTON,
Intervenors-Defendants.
DECLARATION OF DR. KARA ODOM WALKER IN SUPPORT OF INTERVENORSDEFENDANTS' OPPOSITION TO APPLICATION FOR PRELIMINARY INJUNCTION
27
28
Deel. of Dr. Kara Odom Walker in Support ofintervenors-Defendants' Opposition to Application for Preliminary
Injunction (4:18-cv-00167-0)
00384
1
I, Dr. Kara Odom Walker, declare:
1.
2
3
•
(DHSS). I have served as the Secretary of the DHSS since February 6, 2017. Prior
4
to my present post, I served as the Deputy Chief Science Officer at the Patient-
5
Centered Outcomes Research Institute (PCORI) in Washington D.C. from August
6
2012 to January 2017. Furthermore, as a family physician with health services and
7
community-based participatory research training, I previously was an assistant
8
clinical professor in family and community medicine at the University of California,
9
San Francisco, where I developed measurement instruments to better understand
10
integrated care in health systems for diverse populations from July 2010 to July
11
2012.
12
13
•
MPH from Johns Hopkins University. I completed postgraduate training at
15
University of California, San Francisco, and served as a Robert Wood Johnson
16
Clinical Scholar at the University of California, Los Angeles, where I conducted
17
research on the impact of hospital closure on underserved, minority populations.
18
20
21
22
23
24
I graduated with honors from the University of Delaware with a BS in chemical
engineering. Thereafter I received my MD from Jefferson Medical College and
14
19
I am the Secretary of the Delaware Department of Health and Social Services
•
As an advocate for health equity and minority and underserved populations, I was
recognized for leadership by the Harvard Business School's program for leadership
development, the American Medical Association, and the National Medical
Association. I served as past national president of the Student National Medical
Association and past postgraduate physician trustee of the National Medical
Association.
25
2. As one of the largest agencies in state government, DHSS has 11 divisions, employs
26
more than 4,000 people and in one way or another affects almost every citizen in our
27
great state. Our divisions provide services in the areas of public health, social services,
28
Deel. of Dr. Kara Odom Walker in Support oflntervenors-Defendants' Opposition to Application for Preliminary
Injunction (4: 18-cv-OO 167-0)
2
00385
1
substance abuse and mental health, child support, developmental disabilities, long-term
2
care, visual impairment, aging and adults with physical disabilities, state service
3
4
5
6
7
centers, management services, financial coaching, and Medicaid and medical assistance.
The Department includes three long-term care facilities and the state's only public
psychiatric hospital, the Delaware Psychiatric Center.
3. This declaration is submitted in support of the Intervenor-States' Opposition to the
8
Application for Preliminary Injunction. Based on my knowledge and experience,
9
dismantling the Affordable Care Act would cause severe harm to the State of Delaware,
10
11
12
13
14
to its residents and to its economy. In addition to loss of benefits and services and federal
investments to support Delaware's healthcare system, dismantling or suspending
implementation of the Affordable Care Act would cause severe harm to the State of
Delaware, to its residents and to its economy. Delaware would experience harm and
15
increased costs from the dismantling of the state's administrative structure and apparatus,
16
created in compliance with, and to work in conjunction with, the Affordable Care Act.
17
18
19
20
21
22
23
24
25
26
27
28
4. The Affordable Care Act directs billions of dollars directly to Delaware.
• Delaware has received $800 million via Medicaid expansion alone.
5. The Affordable Care Act (ACA) increased access to affordable coverage.
Overall the number of individuals with insurance has increased. In Delaware, the
percentage of population which was uninsured fell from 9.1% in 2013 to 5. 7% in
2016. This translates into the number of people without coverage falling from 83,000
in 2013 to 53,000 in 2016"'
• The ACA expanded coverage through two key mechanisms: Medicaid expansion for
those individuals with the lowest incomes, and federal health subsidies to purchase
coverage in new health insurance Exchanges for those individuals with moderate
mcomes.
Deel. of Dr. Kara Odom Walker in Support oflntervenors-Defendants' Opposition to Application for Preliminary
Injunction (4: 18-cv-OO 167-0)
00386
1
• Medicaid is an important source of healthcare insurance coverage and has resulted in
2
significant coverage gains and reduction in the uninsured rate, both among the low-
3
income population and within other vulnerable populations. As a result of Medicaid
4
expansion Delaware has been able to provide coverage to 11,000 new enrollees and
5
maintain coverage for 50,000 adults from an earlier expansion with enhanced federal
6
financial support, and the state has experienced a large reduction in the uninsured
7
rate.
8
9
10
11
12
6. The ACA has positive economic benefits on states.
• Studies have shown that states expanding Medicaid under the ACA have realized
budget savings, revenue gains, and overall economic growth.
• In Delaware, $500 million has been saved as a result of Medicaid expansion.
7. The ACA has allowed States to test and implement reforms to healthcare
13
delivery systems that support State policy priorities of increasing efficiency and
14
quality of care.
15
• Delaware received Center for Medicare and Medicaid Innovation (CMMI) grants
16
17
18
19
totaling $35 million over four years (2015-2018).
8. All of the foregoing benefits of the Affordable Care Act would be removed if the
Plaintiffs' motion for preliminary injunction were granted.
I declare that the foregoing is true and correct based on information and belief.
20
21
22
23
24
25
Executed on June 6, 2018, in New Castle, Dela ~
---=--
~ r"".Ka~""- O _m W al"!'""' r __,__._ _ _ __
ra ~do .....,'!'-,-, kAn
e_
Cabinet Secretary
Delaware Department of Health
and Social Services
26
27
28
Deel. of Dr. Kara Odom Walker in Support oflntervenors-Defendants' Opposition to Application for Preliminary
Injunction (4: l 8-cv-00167-0)
4
00387
Jun.04.2018
07:00 AM BRODWAY GLASS* MIRROR
607 734 9820
PAGE.
1/
3
IN THF llNITED STATES DISTRICT COllltT
FOR THE NORTHERN DISTRICT OF TEXAS
FORT WORTH DIVISION
Tl·Xi\S. WISCONSIN. ALAR/\Mi\. i\RK/\NS/\S.
ARIZONA. 1--LORIIJA, liH)RlilA, INDIANA,
KANSAS, LOUISIANA, PAUL LePAGF,
(iovcrnor of Maine. novemor Phil Bryant of thL:
Statt: ol' MISSISSIPPI, MISSOlJKL NEU.1{. ASKA,
NORTH DAKOTA, SOUTH CAROLTNA, SOUTH
DAKOTA. TFNNESSFF. UTAH. WEST
VIIHilNIA, N~.:ILL HlJRLEY and JUIIN NANTZ,
Plainli rl:,;,
Civil Action No. 4:18-cv-00167-0
V.
l IN ITFD S IAll•:s OF t\Ml~KICA, l.lNlll:'.l)
STATES OEPARTMLNI 01" Ill.::ALTJI AND
Ill lMAN SERVICES. ALFX AZAR. in his
Olfo.:iul Capai:ily as SH'RLIAK Y OJ< IIEALI II
AND HUMAN SERVICES. UNITED STATES
INTFRNAL RP.VFNlJF SFRVICF. and Di\ YID
J KAl JTJJ-,:R, in his Olfo.:ial Capacity as Acting
COMMISSIONER lW INTERNAL REVENUE.
lkle11da11ts,
CAI .IFORNI/\, CONNECTIClJJ, DISTRICT 01·
COLl.lMIJIA. DELAWARE, HAWAII, TLUNOIS.
K FNTI. Jl'K ·y, M/\SS/\Cl ll JSFITS, MINNFS< HI\
hy and through its Department of Commerce, NEW
JERSEY. NEW Y<)RK. NORTII CAROLINA.
< >RH.a lN. RI IODF ISi AND. VFRMONT.
VIR<,INIA and WASHINGTON,
l11Lcrvcnors-lkknJa11ts.
l.lECLARATION OF SHERRY WHITE IN SUPPORT OF INTERVENORSDRFRNDANTS' OPPOSITION TO APPLICATION ~'OR PR1£LIMINARY
IN.llJNCTION
I. Sherry White, declare:
I..
I am 46 years oltl and a resident ol'Coming, New York .
00388
...
Jun.04.2018
07:00 AM BRODWAY GLASS* MIRROR
'
607 734 9820
PAGE.
2/
My hushand and I arc self-employed small husincss owners. and we have hud to
purchase our own insurance for the last 15 years.
3.
Prior to th.: Affordable Care Act, our family of four pun.::hascd a plan through the
privntc market at $XOO per monlh. While our family is frirtunatc to be relatively
healthy, we found ourselves needing our insurance for several small things over the
years and each lime, we t(1urnl that our plan did not provide thi: 1.:overagt: we nec
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