The Center's work on 'Medicaid' Issues


Medicaid Expansion Decisions Leading States Down Divergent Paths

July 16, 2014 at 2:24 pm

As a growing number of reports increasingly make clear, a state’s decision whether to expand Medicaid as part of health reform has real-life effects on its residents and its businesses.  In the 26 states and the District of Columbia that have expanded Medicaid (see map), the positive benefits are already playing out.  Here’s some of the latest information:

  • Hospitals are providing less uncompensated care.  In Arizona, hospitals reported that the Medicaid expansion is the chief reason for a 30 percent decline in the amount of uncompensated care they have provided so far this year, compared with a year ago.  The Colorado Hospital Association found a similar decline in charity care through April when it surveyed hospitals in 15 states that have expanded Medicaid and 15 that have not.
  • Medicaid expansion is driving large gains in health coverage.  A survey conducted by the Urban Institute finds that while the uninsurance rate is dropping across the country, states that have expanded Medicaid have seen a drop in the percentage of non-elderly adults who are uninsured by more than one-third — a 37.7 decline — while the uninsured rate fell by only 9 percent among states that haven’t expanded.  A survey from the Commonwealth Fund found a similar trend.

States can opt in to the Medicaid expansion at any time, allowing them to extend coverage to millions with the federal government picking up all of the cost of the expansion through 2016 (and nearly all of the cost in the years after), as we have written.  New Hampshire recently started accepting applications for its expansion, with coverage first available on August 15.

But states that refuse to expand leave a coverage gap, where people below the federal poverty line have income too high for Medicaid under prior eligibility rules but too low to qualify for federal subsidies to purchase coverage through the marketplaces.  This means we’re likely to see more stories as in Tennessee where, due to the coverage gap, a couple separated so the wife’s income would be low enough to maintain her Medicaid coverage.

Lower Recidivism: Yet Another Good Reason for States to Expand Medicaid

June 25, 2014 at 2:54 pm

Some opponents of health reform’s Medicaid expansion have cited an estimate that 35 percent of adults newly eligible for Medicaid have been involved in the criminal justice system in the past year.  This figure is highly inflated.

In reality, only about 17 percent of newly eligible adults who enroll in Medicaid will have been in jail or prison.  But even though they will make up about one-sixth rather than one-third of new Medicaid enrollees, their number is significant — and connecting these low-income adults to the health care system can help them avoid returning to jail or prison, as we explain in a new paper.

On any given day, about 750,000 people are in jail; about 75 percent of them for nonviolent offenses.  As many as 90 percent of people in jail are uninsured.  This figure isn’t surprising; until health reform’s coverage expansions took effect this year, there was no pathway to health coverage for poor and low-income adults who weren’t parents living with their minor children, pregnant women, seniors, or people with disabilities.  Not many people with prison or jail stays fall into these categories.

Health reform opened up Medicaid eligibility for all adults with incomes below 138 percent of the poverty line.  So far, 26 states and the District of Columbia have decided to expand coverage.  In addition, adults who aren’t eligible for Medicaid or employer coverage and have incomes between 100 and 400 percent of the poverty line can qualify for premium tax credits to help them afford private coverage through the new health insurance marketplaces.  Roughly half of people leaving jail can qualify for coverage through Medicaid or the marketplaces.  (This figure takes into account that about half of the states have adopted the Medicaid expansion and half have not.)

A number of states and counties are working to connect people released from jail to health coverage for the first time, with a particular focus on people with mental illness and substance-use disorders, given the prevalence of these conditions in this population and the role of these conditions in increasing criminal activity.

States considering whether to expand Medicaid should consider the growing evidence that connecting the jail-involved population to treatment for mental illness and substance abuse can lower the rate at which they return to jail or prison.

For example, a study of a Michigan program to help recently released prisoners obtain community-based health care and social services found that it cut recidivism by more than half, from 46 percent to 21.8 percent.  Similarly, a study that the Justice Department funded in Florida and Washington found that “in both states, 16 percent fewer jail detainees with serious mental illnesses who had Medicaid benefits at the time of their release returned to jail the following year, compared to similar detainees who did not have Medicaid.”

Click here to read the full paper.

Medicaid Primary Care Payment Rate Bump Is Worth Extending

June 19, 2014 at 12:45 pm

An increase in Medicaid primary care payment rates that was included in health reform is scheduled to expire at the end of this year.  But with the need for cost-effective Medicaid primary care rising across the country, the current physician rates should be maintained — and expanded to additional providers — as the Obama Administration and a group of hospitals and doctors have recommended.

Medicaid enrollment has risen by 6 million since October, according to the Centers for Medicare and Medicaid Services, and total enrollment now tops 65 million.  With increased enrollment comes increased need for providers, particularly those providing primary care.  Connecting patients to primary care makes it more likely that they will receive the preventive care and other services to remain healthy and makes it less likely that they will later have to visit the emergency room.

Health reform required states to pay for primary care services at the Medicare rate, which is typically higher than the Medicaid rate, for 2013 and 2014; the federal government picked up 100 percent of the cost of the increase over the state’s regular Medicaid rate for those years.  In boosting physicians’ rates, policymakers intended to increase the number of primary care providers participating in Medicaid in order to ensure access to primary care for Medicaid beneficiaries — both those newly eligible and those who were eligible before 2014.  In Connecticut, the number of primary care providers enrolled in Medicaid has more than doubled since January 2012 and state officials are pushing for an extension of the temporary increase.

Twenty-one organizations representing physicians and hospitals recently wrote to Senate and House leaders to promote a two-year extension of the current payment rate.  The group also asked that policymakers extend the enhanced Medicaid rate to physicians practicing obstetrics and gynecology if their practices provide significant amounts of primary care.  The President’s budget included a one-year extension of the primary care rate increase that would also extend the enhanced rate to include physician assistants and nurse practitioners who provide primary care services.  Both the expansions of the payment increase to additional providers and an extension of the rate increase for at least another year deserve support.

Senate GOP Plan Would Cause Millions to Lose Health Coverage or Block Them From Gaining It in the Future

May 13, 2014 at 3:08 pm

Health reform opponents like Senator Richard Burr (R – NC) have repeatedly attacked the Affordable Care Act (ACA) over the past year by pointing to insurers that cancelled existing, non-ACA-compliant individual market health plans.  Yet, a health plan that Senator Burr and fellow Senate Republicans Tom Coburn (OK) and Orrin Hatch (UT) outlined in January would disrupt existing coverage far more.

As we explain in a new paper, their plan would likely cause millions who now have coverage through Medicaid, the new insurance marketplaces, and their jobs to lose it, while blocking millions more who are expected to obtain health insurance under health reform from gaining it in the future.

The Burr-Coburn-Hatch plan would repeal all of health reform except for certain Medicare provisions.  In its place, it would convert much of Medicaid into block grants and create a new tax credit for people to buy health insurance primarily in the individual market.  The plan has large gaps and lacks many essential details but, based on the public information available, it likely would:

  • Add substantially to the ranks of the uninsured and the underinsured by causing millions of people to lose their existing coverage and by making (or leaving) coverage unaffordable for many people of limited means through changes that would cause their premiums, co-payments, and other out-of-pocket charges to climb significantly;
  • Lead to states facing large shortfalls in federal Medicaid funding that could cause many low-income beneficiaries to become uninsured and go without needed care; and
  • Eliminate or significantly weaken health reform’s consumer protections and market reforms, especially for people with pre-existing conditions.

The Burr-Coburn-Hatch plan claims to ensure affordable health care for patients as an alternative to, and replacement for, the ACA.  In reality, it would make coverage less affordable, add substantially to the ranks of the uninsured, and move the United States backward, toward the poorly functioning individual market that existed before health reform.

Click here to read the full paper.

Moms: Getting Their Families the Coverage They Need

May 12, 2014 at 11:52 am

In a new blog post for Moms Rising, I discuss the important role that mothers play in getting their families the health coverage that they need.  Many already have been responsible for more than 8 million people enrolling in private health coverage during the first open enrollment season for health reform’s insurance marketplaces and another 4.8 million individuals enrolling in Medicaid and the Children’s Health Insurance Program (CHIP).

As I explain for Moms Rising, they’ll continue to be instrumental in getting their families enrolled, even between now and November 15, when the next open enrollment period for the marketplaces begins:

Here are three basic points to keep in mind between now and then:

People who are eligible for Medicaid or CHIP can sign up at any time.  Unlike private coverage, Medicaid and CHIP have no limited enrollment period.  Eligibility for these programs varies by state but, in states that have expanded Medicaid under health reform, adults with income up to 138 percent of the poverty line (about $27,000 for a family of three) can enroll.

Some people can get additional time to finish enrolling in marketplace coverage. Some people who started to enroll before the March 31 deadline and experienced problems with healthcare.gov or have faced other exceptional circumstances can get additional time to complete the process.  In these cases, they may be able to come back to finish their applications now.  In states with their own marketplaces, the deadlines vary, so people who think they may qualify for extensions should check their state’s marketplace website for details.

Major life changes can allow families to enroll in marketplace coverage.  Many people who lose other coverage (such as Medicaid or job-based coverage) or experience other changes can enroll in marketplace coverage during “special enrollment periods” (SEPs).  Although some significant life changes, such as getting divorced, don’t by themselves trigger a SEP, many major life changes do:

  • Losing other health coverage;
  • Moving to a different state, or even within a state if the move changes which plans are available;
  • Getting married; and
  • Having a baby or adopting a child.

Click here to read the full post.