At the Central Iowa Shelter and Services in Des Moines, Iowa, health insurance navigator Andrea Pearce stood in a crowded dining hall on a recent day, shouting instructions on how residents can sign up for Medicaid.
Thousands of homeless people like Jerry Gross could benefit from Iowa鈥檚 Medicaid expansion under the Affordable Care Act (Photo by John Pemble).
鈥淚f you do not have insurance and you want to enroll and you have an e-mail address where you know the password,鈥� she said, 鈥渃ome to the computer lab we will guide you through the application.鈥�
Jerry Gross enthusiastically darted to the front of the line. This tall 56-year-old carries just a duffle bag and his winter coat. He arrived in Des Moines in early December.
He says when he can鈥檛 find a job in one town, he hitchhikes until he can find work. But he鈥檚 uninsured, and taking care of his health is always tough.
鈥淚 take three different water pills for hypertension. I鈥檝e got like 10 more days of that left, and after that what do you do?鈥� he says.
When the federal Affordable Care Act called for states to expand Medicaid programs to cover people like Gross, Iowa Republican Gov. Terry Branstad refused. He said he feared the federal government wouldn鈥檛 come through on its promise to fund the expansion to include childless adults. Iowa was one of many states that initially refused all or part of the federal funds offered.
鈥淲e鈥檙e not just one of those states that said, 鈥極h yeah, we鈥檒l take the federal money.鈥� No. We said 鈥榥o,鈥� 鈥� Branstad said during a recent news conference.
Eventually Branstad said 鈥測es,鈥� but only if Iowa could take the money on its own terms. The state legislature, which is evenly split between Republicans and Democrats, came up with an alternative: Federal expansion dollars would pay for managed care policies that poor people would select on the HealthCare.gov site.
Iowa鈥檚 plan also provides incentives for people on Medicaid to monitor their health. Branstad calls it having 鈥渟kin in the game.鈥�
Iowa is one of a that negotiated or are negotiating with the federal government to customize their Medicaid expansion and still get federal funding. Branstad notes that 鈥渙ther states, like Tennessee and Pennsylvania, are looking at our plan.鈥�
The federal Department of Health and Human Services鈥� decision to a waiver to try this idea is not surprising, says , executive director at the Georgetown University鈥檚 Center for Children and Families, a policy research center. She says that the Obama administration 鈥渋s willing to bend over backwards to get to 鈥榶es,鈥� 鈥� to show Republican governors how much flexibility they have in experimenting with Medicaid expansion in their states.
But 鈥渢here are some lines they can鈥檛 and will not cross,鈥� Alker says. While Iowa beneficiaries have to pay something for premiums and non-emergency care, recipients 鈥渃an鈥檛 be disenrolled if they鈥檙e unable to pay those premiums,鈥� she says. 鈥淭hat鈥檚 important, because we already have plenty of evidence to suggest that charging premiums to people below [the] poverty [line] will mean that they can鈥檛 afford them and they鈥檙e likely to lose their coverage.鈥�
Alker worries that the Iowa plan鈥檚 for non-emergency medical transportation, which is included in coverage in other states, could have repercussions.
鈥淭hey鈥檙e covered for emergency transportation. They鈥檙e going to get that ambulance to get to the hospital. But we want to make sure folks are able to get their preventative and primary care appointments,鈥� Alker says. 鈥淲hen you鈥檙e talking about people who literally could have limited or no income, that becomes a real barrier.鈥�
People are already signing up, so that they鈥檒l be enrolled in Medicaid in Iowa beginning Jan. 1.
This story is part of a reporting partnership between NPR and Kaiser Health News.