The Center's work on 'Medicaid' Issues


Indiana Should Revise Medicaid Waiver Proposal

October 17, 2014 at 11:01 am

Indiana has proposed to expand Medicaid and extend health coverage to as many as 374,000 uninsured Hoosiers through the Healthy Indiana Plan (HIP) 2.0.  As currently designed, however, the proposal would create barriers to coverage for low-income individuals and cause substantial numbers of people to remain uninsured, as we explain in a new paper.  The state should modify its proposal to ensure that all newly eligible adults are actually able to participate and receive necessary health care services on a timely basis.

HIP 2.0 would be a new demonstration project, or “waiver,” that incorporates features from the state’s existing Medicaid waiver, which was approved prior to the enactment of health reform and offers limited coverage to about 40,000 low-income adults.

Although Medicaid waivers give states additional flexibility in how they design their Medicaid programs, the Medicaid statute requires that waivers must test new approaches to Medicaid while promoting the program’s objective of delivering health care services to vulnerable populations that can’t otherwise afford care.  As proposed, HIP 2.0 falls short of meeting this standard in several important respects: aspects of the plan would almost certainly result in substantial numbers of low-income people being unable to receive health insurance and access care for significant periods of time.  Indiana should modify those parts of the proposal to ensure that newly eligible Medicaid beneficiaries can actually enroll in coverage and receive necessary health care services.

HIP 2.0 does drop some problematic features of the state’s existing Medicaid waiver, such as a cap on the number of enrollees and annual and lifetime dollar limits on coverage, to comply with changes that the health reform law made to Medicaid.  But the state is seeking approval to maintain certain other features of its current waiver that are inconsistent with the Medicaid expansion, such as charging premiums to people with little income and delaying the start date for coverage.  A substantial body of research, including Indiana’s own experience under its existing Medicaid waiver, demonstrates that charging premiums to people with low incomes discourages them from enrolling in and maintaining coverage.

Click here to read the full paper.

Do Medicaid and SNAP Reach Those Who Most Need Them?

September 30, 2014 at 12:30 pm

Millions of low-income people qualify for both Medicaid and SNAP (formerly food stamps), but the federal government doesn’t regularly assess how many of them actually receive both.  That’s a significant omission: Medicaid and SNAP address the most basic needs of our poorest citizens, and health care and nutrition assistance likely produce more powerful results when provided together.  A new Urban Institute paper examining joint participation among eligible children and non-elderly adults in five states — something the federal government could do for all states every year — suggests there is substantial room for improvement.

Urban Institute researchers calculated joint participation rates for 2011 in Colorado, Idaho, Illinois, North Carolina, and South Carolina.  (These states participate in the Work Support Strategies initiative, which is developing and testing better ways to deliver key supports for low-income working families.)  They found significant gaps in joint enrollment: in four of the states, only about two-thirds of non-elderly adults and children who were eligible for both Medicaid and SNAP actually received both (see graph).

The findings are consistent with our 2011 report’s finding that a large share of poor children — who are very likely eligible for both Medicaid and SNAP — aren’t enrolled in both.

(To be sure, both findings predate health reform implementation, so they don’t reflect participation of many newly eligible low-income adults in states that expanded Medicaid.  Nor do they reflect the major changes in Medicaid application and enrollment systems that health reform requires in order to improve participation.)

Over 40 states co-administer Medicaid and SNAP for low-income families, often using joint forms, the same computer systems, and the same eligibility workers, so one program’s performance often depends on the other’s.  Yet the federal agencies that oversee the two programs issue program policy, oversee operations, and assess state performance on the two programs separately.

States are key partners in delivering the safety net, so it’s important to take a holistic view of their performance, not just a program-by-program approach.  An annual federal assessment of the share of Medicaid- and SNAP-eligible people in each state who actually receive both would better inform federal and state officials on how well we serve our poorest families and individuals.

5 Takeaways From Last Week’s Figures on Poverty, Inequality, and Health Coverage

September 25, 2014 at 12:32 pm

Here are five key findings from our analyses (here and here) and blog posts on the new figures from the Census Bureau and Centers for Disease Control and Prevention (CDC).

  1. While poverty and median income improved last year for families with children,poverty rates reached record highs for childless families and individuals.  The poverty rate for individuals not living in families (people living alone or only with non-relatives) rose to 23.3 percent in 2013, the highest in over 30 years.  The poverty rate for childless families (childless couples, older couples or other families whose children have moved away or turned 18, and other relatives who live together), while much lower at 6.2 percent, was also the highest in over three decades.
  1. Income inequality remained historically high.  The share of the nation’s income going to the bottom fifth of households remained at 3.2 percent, tied for the lowest level on record with data back to 1967.  The ratio of the median income of the top fifth of households to that of the bottom fifth topped 12 to 1 for the first time on record, with data back to 1967.
  1. Austerity policies limited progress on jobs, income, and poverty.  Instead of responding to continued weak job growth by creating jobs (such as by expanding infrastructure investments), policymakers adopted various austerity policies that constrained consumer spending and employment growth.  Sequestration budget cuts, for example, lowered appropriations for most discretionary programs by 5 to 8 percent in 2013.  Policymakers also allowed a payroll tax holiday to expire after December 2012 and allowed tax cuts for very high-income individuals to expire (though the latter mattered less for consumer demand since high-income people’s spending is less sensitive to tax changes).  The Congressional Budget Office projected in early 2013 that these measures would reduce economic growth over the year by about 1½ percentage points and lower employment by more than 1 million jobs.
  1. The uninsured rate fell slightly last year and is falling further in 2014, as health reform’s major coverage expansions take effect.  The share of Americans without health coverage fell from 14.8 percent to 14.5 percent in 2013, according to Census’ American Community Survey.  And preliminary data from CDC — the first government survey data that reflect the early impact of the coverage expansions (the Medicaid expansion and subsidized marketplace coverage) — show that the number of uninsured fell by 3.8 million in the first quarter of 2014.
  1. The coverage gap between states that have expanded Medicaid and states that haven’t is widening.  In 2013,before the expansion took effect, some 14.1 percent of the people in the 27 expansion states (including Washington, D.C.) were uninsured, compared to 17.3 percent in the 24 non-expansion states.  Figures for the first part of 2014 show the gap is widening.  For example, CDC data show that 15.7 percent of non-elderly adults in expansion states were uninsured in the first quarter of 2014, compared to 21.5 percent for non-expansion states (see graph).

Coverage Gap Widening Between Medicaid Expansion States and Others

September 18, 2014 at 11:53 am

People in states that have adopted health reform’s Medicaid expansion had a lower uninsured rate in 2013 (before the expansion took effect) than people in non-expansion states — and non-expansion states are falling further behind in 2014, several recent government and independent surveys reveal.

Some 14.1 percent of the people in the 27 states (including Washington, D.C.) that have expanded Medicaid lacked health insurance in 2013, compared to 17.3 percent in the 24 non-expansion states, according to the Census Bureau’s American Community Survey (see chart).

Next year’s Census data, which will reflect the substantial coverage gains expected in expansion states in 2014 due to the expansion (which took effect January 1), should show a further widening of this coverage gap.

Results from several independent surveys — and this week from the Centers for Disease Control and Prevention (CDC), the first government survey data showing health reform’s early impacts — show that this is already happening.  For example, the Urban Institute’s Health Reform Monitoring Survey found that the uninsured rate for non-elderly adults in expansion states fell from 16.2 percent to 10.1 percent between the third quarter of 2013 and the second quarter of 2014, compared to a decline from 20.0 percent to 18.3 percent in non-expansion states.

Health reform’s Medicaid expansion creates a pathway to coverage for all non-elderly adults with incomes up to 138 percent of the poverty line, including, for the first time, low-income adults without children.  However, the 2012 Supreme Court decision upholding health reform made the expansion a state option.  States can opt in to the expansion at any time; the federal government will pick up all of the cost through 2016 and nearly all of the cost thereafter.

Census Data Show Continued Wide Disparities in Health Coverage

September 17, 2014 at 11:46 am

Certain groups of Americans continue to be uninsured at particularly high rates, the new Census Bureau data show.  African Americans and Hispanics, residents of the South and West, adults under age 35, and households with incomes under $50,000 had uninsured rates in 2013 well above the national average of 13.8 percent (see chart).  Hispanics’ 24.3 percent uninsured rate, for example, was nearly twice the national average.

These estimates, from the Current Population Survey (CPS), are the best source for comparing coverage rates among population groups in a single year but can’t be compared to CPS estimates from previous years because of changes to the CPS questions for 2013.  For health coverage trends over time, one should look instead to Census’ American Community Survey data, which we discussed yesterday.

Health reform’s major coverage expansions — the Medicaid expansion in many states to cover more low-income adults and the availability of subsidies for private marketplace coverage — will help reduce the disparities in health coverage among population groups.  But the expansions didn’t begin until 2014, so the new Census figures for 2013 don’t capture those coverage gains.  The Centers for Disease Control and Prevention released data yesterday covering the first quarter of 2014, and they show that the coverage gains in 2014 were greatest among some of the groups with the highest uninsured rates, including young adults, Latinos, and low-income households.