iProtean—Medicaid Enrollment Robust But Many Left Out

Some states have reported a surge in Medicaid enrollments as part of the Affordable Care Act’s (ACA’s) push to expand insurance coverage, despite the reported IT problems in the federal and some state-operated exchanges.


The ACA expanded Medicaid coverage to all residents with household incomes up to 138 percent of the poverty level. However, the Supreme Court ruling in June 2012 made the expansion of Medicaid optional for states; as a result, 26 states are not planning to implement the expansion as of September 2013. The expansion of Medicaid eligibility was expected to add nine million beneficiaries to Medicaid in 2014, according to the nonpartisan Congressional Budget Office.


The remaining states appear to have had a modicum of success in enrolling these new Medicaid recipients. The Healthcare Financial Management Association (HFMA) cited progress in Arkansas’ Medicaid program. It noted that early success in Arkansas was ‘very encouraging’ to the state’s hospitals, and that hospital officials hope the ACA’s expanded coverage of previously uninsured patients will help offset some of the $379 billion in Medicare hospital cuts the law includes from 2012-2021. (“State Medicaid Enrollments Outpace Federal Efforts,” HFMA Weekly News, October 18, 2013)


Arkansas and several other states have had success primarily because they searched their other public assistance programs (e.g., Supplemental Nutrition Assistance Program) for applicants whose incomes would qualify them for the expanded Medicaid program.


Andrea Maresca, director of federal policy and strategy for the National Association of Medicaid Directors speculated that some states have avoided the challenges experienced by healthcare.gov because “this isn’t entirely new to the states.” HFMA cites “the longstanding experience of states with the process.” (“State Medicaid Enrollments Outpace Federal Efforts,” HFMA Weekly News, October 18, 2013)


Arkansas estimates the expansion will add 220,000 newly eligible residents to the program. The state’s Medicaid expansion uses private insurance sold in the new marketplace to cover much of the newly eligible population.


Most enrollment has been through a combination of approaches; for example, in Arkansas, people sought enrollment through the state website, phone calls and in-person applications. Some state residents were found eligible by the state and confirmed their interest through a state letter writing campaign. Non-respondents will be auto-enrolled.


In some states, web-based enrollment has been working; for example, Washington state reported that 88 percent of the nearly 25,000 applicants who completed enrollments on its insurance website from October 1 through October 14 were added to the state’s Medicaid program.


What About the Other States?


A new report from Kaiser examines the impact of the decision by states to not expand Medicaid coverage as anticipated under the ACA. “In states that do not expand Medicaid, over five million poor uninsured adults have incomes above Medicaid eligibility levels but below poverty and may fall into a ‘coverage gap’ of earning too much to qualify for Medicaid but not enough to qualify for Marketplace premium tax credits. Most of these people have very limited coverage options and are likely to remain uninsured. (“The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid,” The Kaiser Commission on Medicaid and the Uninsured, Issue Brief, October 2013)


Because the ACA envisioned individuals with incomes up to 138% of poverty receiving Medicaid, the law does not provide premium tax credits for the lowest incomes. But most of these ‘coverage gap’ adults do not have access to employer-based coverage through a job and can’t afford coverage on their own.


The range of Medicaid eligibility among the 26 states varies widely; only four states not expanding Medicaid (Alaska, Maine, Tennessee, and Wisconsin) cover parents up to at least poverty, and eligibility limits in some states are less than 20% of the poverty level (16% in Alabama, 19% in Texas). Of the states not moving forward with the expansion, only Wisconsin provides Medicaid coverage to adults without dependent children. The median across all 26 states is 47 percent of the federal poverty level. (“The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid,” The Kaiser Commission on Medicaid and the Uninsured, Issue Brief, October 2013)


The safety net of clinics and hospitals that has traditionally served the uninsured population will continue to be stretched in these 26 states. States may decide to implement the expansion at a later date—there is no deadline for implementing the Medicaid expansion. “. . . more than five million poor adults in states not expanding Medicaid coverage will be ineligible for assistance, while millions more who earn more than they do will receive tax credits to help them pay for coverage in the new insurance Marketplaces,” the authors of the Kaiser report noted.


Additional sources for this posting: “Kaiser Says 5 Million Uninsured Adults May Fall into ACA ‘Coverage Gap’ in States That Choose Not to Expand Medicaid,” AHLA, October 18, 2013.


To read the Kaiser Issue Brief, please click here.




iProtean subscribers, please look for your new course, Making Difficult Decisions About Services & Programs, Part One in your library. This advanced Finance course features Marian Jennings, Nathan Kaufman and Lisa Goldstein.



For a complete list of iProtean courses, click here.

For more information about iProtean, click here.