Via Greg Sargent, we learn today that Iowa could soon join the ranks of states agreeing to expand Medicaid coverage in exchange for a waiver from HHS allow it to do things not normally permissible under Medicaid:

I’m told that the Department of Health and Human Services has just notified Iowa that it is prepared to grant the state a waiver to pursue much of what it has asked for in response to its request for HHS approval to expand Medicaid-funded coverage to low income Iowans on the state’s own terms. “Iowa has proposed a lot of innovative ideas around the Medicaid expansion, and we’re really pleased to approve the waiver today,” an HHS official tells me.

This could make it more likely Iowa takes federal money to expand coverage — which could impact as many as 150,000 people — and that, in turn, could also signal that other states similarly looking to expand Medicaid in their own way could have an easier time doing that. This is a way out for Republican governors who are hostile to the law, but under internal pressure to accommodate the Medicaid expansion, since it means bucket-loads of federal money to cover their own constituents.

That’s all true, but progressives pleased with the news that states are gradually getting with the program should pause at least a moment to wonder if the waivers HHS is granting carry their own risks.

The one description I’ve found of Iowa’s “innovative” Medicaid “reforms” involves putting one group of beneficiaries though a “healthy choice” program, and another into the Obamacare exchanges where they will obtain private insurance. Perhaps these are good things, and perhaps the coverage expansion is worth whatever states do, but the big picture here is that some states are using ACA to secure total federal financing for a conservative overhaul of Medicaid (in Florida, the waiver Rick Scott had secured before the legislature killed his expansion proposal allowed him to privatize all of Medicaid, not just the portion affecting the new enrollees). It would be smart to keep an eye on these deals, which could have long-range implications for how health care is delivered for our neediest citizens. Lord knows Medicaid is far from a perfect program, but leaving it even more to the states’ tender mercies isn’t necessarily the solution.

Ed Kilgore

Ed Kilgore is a political columnist for New York and managing editor at the Democratic Strategist website. He was a contributing writer at the Washington Monthly from January 2012 until November 2015, and was the principal contributor to the Political Animal blog.