Medicaid Expansion Essay

Scenario

You are the director of community affairs for the health lobby organization, Pathways to a Healthy America. In 2010, President Barack Obama signed the Affordable Care Act into law. As a result, millions of Americans who were previously uninsured gained access to the healthcare system. One of the initial provisions of the Act required individual states to expand the eligibility criteria for Medicaid. The program’s costs would be absorbed by the federal government at a rate of 100% for the first three years of program participation which would decrease to 90% after 2020, still, considerably higher than previous funding by the federal government. However, in 2012, the Supreme Court ruled the mandate unconstitutional allowing individual states to voluntarily “opt” out of the Medicaid expansion program. As a result of the various states’ decision to “opt” out of the ACA’s Medicaid expansion, millions of adults fell into the critical coverage gap. Your organization represents a state which has decided to forego participation in the ACA expansion program. The decision was met with both praise and criticism. Medicaid Expansion Essay

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It has now been a few years since the decision and your organization has gathered information on the impact of the decision in order to advocate for Medicaid reform during the next state legislative session.

You are required to write an advocacy report to state lawmakers in which you advocate for either participating in the original expansion program or participating with conditions (waivers) to address the critical gap in coverage for vulnerable adults in your state. Waivers such as Section 1115 enable for alternative implementation of Medicaid expansion and allow states to impose restrictions which may result in a denial of Medicaid eligibility for individuals who do not meet those restrictions, i.e., work requirements. Medicaid Expansion Essay

Instructions
State: Texas

Research the Medicaid expansion program offered through the Affordable Care Act (ACA) as well as Medicaid reform initiatives using waivers to increase access to Medicaid. Determine, based on your state’s profile, which process (the ACA’s expansion program or the use of waivers) is most beneficial to your state. Include a comprehensive, well-supported recommendation for participation in Medicaid reform using either the ACA’s program or a modified reform process using waivers. Medicaid Expansion Essay

Your advocacy report should describe your state’s (Texas) current Medicaid program including its eligibility criteria, demographics, Medicaid spending and savings since the ACA’s implementation, and comprehensive details of current or pending waivers. You should also include a discussion (benchmark) on another state’s success with Medicaid reform using your recommended strategy (the ACA’s expansion program or the use of the specific types of waivers for which you propose). Medicaid Expansion Essay

In 2009 there were 50.7 million people, 16.7% of the population, without health insurance. Americans all over the country are working and yet they still can’t afford to pay the high cost of health insurance for themselves and their families. Under the Affordable Care Act of 2010, which was signed by Obama on March 23, 2010, thirty two million Americans who were previously not eligible for Medicaid may now have the opportunity to be covered. If this act is passed in North Carolina then it will be expanded to cover nearly all of the 1.5 million North Carolinians who are without health insurance. If more Americans are covered under the Medicaid that they need then…show more content…
The Medicaid expansion will cost the federal government between 15-20 billion dollars in the first six years, but the federal government is paying for 93% of the direct expansion costs. But with the expansion, the greater majority of people will be able to pay their own medical bills, which means the state and local governments will save millions of dollars. If Medicaid is not expanded to the millions who have low incomes and aren’t insured, then starting in 2014 Americans who don’t pay for health insurance and aren’t eligible for Medicaid will then be issued a tax. In 2014 Americans will have to pay 95 dollars or one percent of their income, which ever is higher. The tax will only increase from there. In 2015 Americans will have to pay 325 dollars or two percent of their income, and in 2016 the tax will increase to 695 dollars or 2 and a half percent of their income. Americans who make $200,000 or more annually and couples with incomes above $250,000 will have a tax increase to help cover the costs of the program. Some may argue that the expansion of Medicaid is a bad idea because of the potential shortage of healthcare professionals. A new study has predicted that the expansion of Medicaid could lead to a shortage of 52,000 primary care physicians by 2025, it also states that visits to the doctors will increase from 462 million a year to 565 million a year, which will strain the system. Medicaid Expansion Essay

In 2009 there were 50.7 million people, 16.7% of the population, without health insurance. Americans all over the country are working and yet they still can’t afford to pay the high cost of health insurance for themselves and their families. Under the Affordable Care Act of 2010, which was signed by Obama on March 23, 2010, thirty two million Americans who were previously not eligible for Medicaid may now have the opportunity to be covered. If this act is passed in North Carolina then it will be expanded to cover nearly all of the 1.5 million North Carolinians who are without health insurance. If more Americans are covered under the Medicaid that they need then …show more content…
But what would cause the shortage of healthcare professionals? How do we know they will pass the fees onto consumers? Both of these things are just predictions. If Medicaid is expanded under the Affordable Care Act of 2010 then millions of Americans all over the country who do not qualify for Medicaid may be eligible for a more affordable health insurance plan. Expanding Medicaid is the right choice in the end because more Americans can be covered and it will save millions of dollars in the long run. Expanding Medicaid gives families the security they need and important benefits. Medicaid Expansion Essay

This literature review includes studies, analyses, and reports published by government, research, and policy
organizations using data from 2014 or later. This brief only includes studies that examine impacts of the
Medicaid expansion in expansion states. It excludes studies on impacts of ACA coverage expansions generally
(not specific to Medicaid expansion alone), studies investigating potential effects of expansion in states that
have not (or had not, at the time of the study) expanded Medicaid, and reports from advocacy organizations
and media sources. Findings are separated into three broad categories: Medicaid expansion’s impact on
coverage; access to care, utilization, affordability, and health outcomes; and economic outcomes for the
expansion states. The Appendix at the end of the brief provides a list of citations for each of the included
studies, grouped by the three categories of findings.
Recently published studies from late 2017 and early 2018 have continued to support earlier findings while
using the additional years of experience with expansion to deepen findings in many areas, including
expansion’s effects on health outcomes, access to services and medications for behavioral health and
other needs, and providers’ financial stability. Among other findings, new studies in these areas show that
expansion is associated with infant mortality rate reductions, increases in cancer diagnosis rates
(especially early-stage diagnosis rates), increases in prescriptions for and Medicaid coverage of
medications to treat opioid use disorder and opioid overdose, and reduced probability of hospital closure
(particularly in rural areas). Medicaid Expansion Essay
We will continue to monitor and update these findings as additional studies and state experiences provide
insight into how various factors shape coverage, access to care, and costs in Medicaid expansion states
and as states continue to consider expansion and reshape Medicaid coverage. While future research will
be necessary to study the effects of new waiver provisions recently approved by or pending approval from
the Trump administration, findings from this literature review on states with existing expansion waivers
(such as Indiana) suggest that adding new restrictions or program complexities to Medicaid through
Section 1115 waivers could compromise coverage and access gains achieved under expansion or slow
future progress.
Impacts on Coverage
Uninsured Rate and Medicaid Coverage Changes
Studies show that Medicaid expansion results in significant coverage gains and reductions in
uninsured rates.
 States expanding their Medicaid programs under the ACA have seen large increases in Medicaid
enrollment, driven by enrollment of adults made newly eligible for Medicaid as well as enrollment
growth among individuals who were previously eligible for but not enrolled in Medicaid (known as
the “woodwork” or “welcome mat” effect that occurred largely due to incentives to increase
enrollment in coverage provided under the broader ACA). In comparison, non-expansion states
have experienced slower enrollment growth.2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24 Medicaid Expansion Essay

 Numerous analyses demonstrate that Medicaid expansion states experienced large reductions in
uninsured rates and that these reductions significantly exceed those in non-expansion
states.25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56
The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review 3
o Recent studies have shown that expansion-related enrollment growth in Medicaid and
declines in uninsured rates in expansion states continued in 2015 and 2016, and that the
gap between coverage rates in expansion and non-expansion states continued to widen
after 2014. One study found that the greater uninsured rate decline in expansion
compared to non-expansion states was isolated among the population that is ineligible for
ACA coverage in non-expansion states (those below 100% FPL).57,58,59,60,61 ,62
 The sharp declines in uninsured rates among the low-income population in expansion states are
widely attributed to gains in Medicaid coverage.63,64,65,66,67,68
 Research does not support a relationship between states’ Medicaid expansion status and home
and community-based services (HCBS) waiver waiting lists. One study found that most expansion
states either had no HCBS waiver waiting list or had a decrease in their waiting list from 2014 to
2015, and more non-expansion states than expansion states experienced an HCBS waiver
waiting list increase between 2014 and 2015.69

 Studies exploring the potential for Medicaid expansion to “crowd-out” private insurance have
found mixed results, with most showing no evidence of “crowd-out” and some showing slight
declines in private coverage in expansion states following expansion.70,71,72,73,74,75,76,77,78
Similar coverage gain patterns have occurred within specific vulnerable populations. Medicaid Expansion Essay
 While many studies focused on the low-income population broadly, several studies identified
larger coverage gains in expansion versus non-expansion states for specific vulnerable
populations, including young adults, prescription drug users, people with HIV, veterans, parents,
mothers, women of reproductive age (with and without children), children, lesbian, gay, and
bisexual adults, newly diagnosed cancer patients, women diagnosed with a gynecologic
malignancy, low-income workers, low-educated adults, early retirees, and childless adults with
incomes under 100% FPL.79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102
 Multiple recent analyses demonstrate that Medicaid expansion is having a disproportionately
positive impact in rural areas in expansion states, where growth in Medicaid coverage and
declines in uninsured rates have exceeded those in metropolitan areas in expansion states and
both rural and metropolitan areas in non-expansion states. One study found higher Medicaid
growth rates in metropolitan counties compared to rural counties in both expansion and nonexpansion states, but the geographic differential in growth rates was much less dramatic in
expansion states and analysis at the state level showed much variability across the
states.103,104,105,106
 Multiple studies showed that this trend of larger uninsured rate reductions and Medicaid coverage
gains in expansion states compared to non-expansion states occurred across the major
racial/ethnic categories. Additional research also suggests that Medicaid expansion has helped to
reduce disparities in coverage by income and age, and research shows improvements in
disparities by race/ethnicity, with mixed outcomes for some specific racial and ethnic
groups.107,108,109,110,111,112,113,114,115,116 Medicaid Expansion Essay
The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review 4
 One 2017 study demonstrated a clear “welcome-mat” effect of Medicaid expansion on enrollment
in public coverage among children who were already eligible for Medicaid. Enrollment increases
in 2014 and 2015 among children whose parents became newly eligible for Medicaid under the
expansion outpaced coverage increases among children in families without newly eligible parents
by more than double.117 Medicaid Expansion Essay

Coverage Effects Under Section 1115 Medicaid Expansion Waivers
States implementing the expansion through a waiver have seen similar gains in coverage, but
some provisions in these waivers may present barriers to coverage.
 Studies show that states expanding Medicaid through Section 1115 waivers have experienced
coverage gains that are similar to gains in states implementing traditional Medicaid expansions.
Research comparing Arkansas (which expanded through a premium assistance model) and
Kentucky (which expanded through a traditional, non-waiver model) showed no significant
differences in uninsured rate declines between 2013 and 2015 in the two states. An analysis of
expansion waiver programs in Michigan and Indiana showed that both states experienced
uninsured rate reductions between 2013 and 2015 that were higher than the average decrease
among expansion states as well as large gains in Medicaid enrollment.118,119,120,121
 Data from Indiana, which implemented the expansion through a Section 1115 waiver, show that
its required monthly contributions may have created an enrollment barrier for some adults. In the
Healthy Indiana Plan (HIP) 2.0 Medicaid expansion program, individuals above 100% FPL are
either not enrolled or disenrolled from HIP 2.0 coverage for unpaid monthly contributions. A report
assessing the program showed that between February 1, 2015 and November 30, 2016, 57,189
members were disenrolled or not enrolled due do non-payment (representing 29% of those that
could be affected by the policy).122,123 Medicaid Expansion Essay

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 Evidence also suggests that beneficiaries and other stakeholders often do not fully understand
complex enrollment policies such as the HIP 2.0 monthly contribution policy, and these policies
can deter eligible people from enrolling in coverage. The March 2017 HIP 2.0 evaluation found
that 14% of all HIP enrollees above 100% FPL, 33% of individuals who were disenrolled for not
making a monthly contribution, and 40% of individuals who were not enrolled because they did
not make a first monthly contribution reported being unaware that they could be disenrolled for
non-payment.124,125,126
Impacts on Access to Care, Utilization, Affordability, and
Health Outcomes
Access to Care and Utilization
Most research demonstrates that Medicaid expansion positively impacts access to care and
utilization of health care services among the low-income population, but some studies have not
identified significant effects in these areas. Medicaid Expansion Essay