Jump to content

Medicaid coverage gap

Add links
From Wikipedia, the free encyclopedia
This is an old revision of this page, as edited by Niceguyedc (talk | contribs) at 20:40, 31 May 2023 (v2.05 - Repaired 3 links to disambiguation pages - (You can help) - Georgia, New York, Washington / Fix errors for CW project (Whitespace characters after heading)). The present address (URL) is a permanent link to this revision, which may differ significantly from the current revision.

Status of Medicaid expansion by state as of March 2023[1]
  Has adopted Medicaid expansion
  Not adopted Medicaid expansion

In the context of American public healthcare policy, the Medicaid coverage gap refers to uninsured people who do not qualify for marketplace assistance under the Affordable Care Act (ACA) and reside in states that have not adopted Medicaid expansion under the ACA. People within this categorization have incomes above the eligibility limits for Medicaid set by their state of residence but fall below the federal poverty line (FPL), resulting in deficient access to affordable health insurance. As of March 2023, an estimated 1.9 million Americans in 10 states are within the Medicaid coverage gap according to the Kaiser Family Foundation. Approximately 97 percent of this cohort lives in the Southern U.S., with a majority living in Texas and Florida; Texas has the largest population of people in the cohort, accounting for 41 percent of people in the coverage gap.[2]

Expansion of Medicaid was a key aspect of the ACA when it was signed into law by President Barack Obama in March 2010, supporting the legislation's goal of ensuring universal health care in the U.S. by raising the income threshold for Medicaid eligibility to 138 percent of the FPL among nonelderly adults. States choosing to participate in Medicaid expansion would also have additional Medicaid costs fully covered by the federal government in the first three years of expansion slated to begin in 2014, with a stepwise decrease in the federal government's share to 90 percent in 2020 and thereafter. Opponents of the legislation asserted that the federal government's conditioning of additional funding for Medicaid on adoption of expansion was unconstitutionally coercive. The Supreme Court held in National Federation of Independent Business v. Sebelius that adoption of Medicaid expansion by states was effectively optional, and that states could continue with their preexisting Medicaid requirements without risk of defunding. The decision not to implement Medicaid expansion in some states after the ACA took effect in 2014 led to a "gap" in coverage for residents of those states with incomes too low for subsidized insurance in the ACA's newly established health insurance marketplaces and incomes too high to qualify for the non-expanded Medicaid in their states. Only 24 states adopted Medicaid expansion when ACA initially took effect. As of March 2023, 40 states and the District of Columbia have adopted Medicaid expansion, leaving 10 states that have not.

Population characteristics

As initially passed, the ACA was designed to provide universal health care in the U.S.: those with employer-sponsored health insurance would keep their plans, those with middle-income and lacking employer-sponsored health insurance could purchase subsidized insurance via newly-established health insurance marketplaces, and those with low-income would be covered by the expansion of Medicaid. However, the U.S. Supreme Court ruling in National Federation of Independent Business v. Sebelius (2012) rendered state adoption of Medicaid expansion optional. Governors in several Republican-leaning states announced that they would not expand Medicaid in response, leading to a gap in insurance coverage.[3] The Medicaid coverage gap includes nonelderly people with incomes that are below the federal poverty line (FPL), making them ineligible for subsidized marketplace insurance under the Affordable Care Act (ACA), but have incomes higher than their state's limit for Medicaid eligibility as their state has not adopted Medicaid expansion as prescribed by the ACA.[4][2] The gap also includes childless adults who are ineligible for Medicaid regardless of income in these states (with the exception of Wisconsin, which permits Medicaid coverage via waiver).[2]

As of March 2023, an estimated 1.9 million people are in the Medicaid coverage gap, residing in Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming. Out of the cohort, 97 percent live in the Southern United States where most of the non-expansion states are located, with Texas, Florida, and Georgia accounting for nearly three-quarters of the Medicaid coverage gap. Childless adults account for 76 percent of the coverage gap, and people of color account for around 61 percent of the cohort. Within the ten states that have not opted for Medicaid expansion, the median income limit for eligibility in the traditional Medicaid program is 38 percent of the FPL.[a] The uninsured rate within the non-expansion states was 15.4 percent in March 2023 compared to 8.1 percent in expansion states.[2]

Medicaid expansion

Medicaid expansion by state[1]
Subdivison Status Implemented
Alabama Not adopted —
Alaska Implemented September 1, 2015
Arizona Implemented January 1, 2014
California Implemented January 1, 2014
Colorado Implemented January 1, 2014
Connecticut Implemented January 1, 2014
Delaware Implemented January 1, 2014
District of Columbia Implemented January 1, 2014
Florida Not adopted —
Georgia Not adopted —
Hawaii Implemented January 1, 2014
Idaho Implemented January 1, 2020
Illinois Implemented January 1, 2014
Indiana Implemented February 1, 2015
Iowa Implemented January 1, 2014
Kansas Not adopted —
Kentucky Implemented January 1, 2014
Louisiana Implemented July 1, 2016
Maine Implemented January 10, 2019
Maryland Implemented January 1, 2014
Massachusetts Implemented January 1, 2014
Michigan Implemented April 1, 2014
Minnesota Implemented January 1, 2014
Mississippi Not adopted —
Missouri Implemented October 1, 2021
Montana Implemented January 1, 2016
Nebraska Implemented October 1, 2020
Nevada Implemented January 1, 2014
New Hampshire Implemented August 1, 2014
New Jersey Implemented January 1, 2014
New York Implemented January 1, 2014
North Carolina Adopted —
North Dakota Implemented January 1, 2014
Ohio Implemented January 1, 2014
Oklahoma Implemented July 1, 2021
Pennsylvania Implemented January 1, 2015
Rhode Island Implemented January 1, 2014
South Carolina Not adopted —
South Dakota Adopted —
Tennessee Not adopted —
Texas Not adopted —
Utah Implemented January 1, 2020
Vermont Implemented January 1, 2014
Virginia Implemented January 1, 2019
Washington Implemented January 1, 2014
West Virginia Implemented January 1, 2014
Wisconsin Not adopted —
Wyoming Not adopted —
Uninsured rates in the U.S.
Graphic with bar charts depicting uninsurance rates by income level
Comparison of uninsured rates between states based on their Medicaid expansion participation in 2017 and 2018
Line chart showing declines in the percentage of uninsured Americans after the creation of Medicare, Medicaid, and the implementation of the ACA
Percentage of individuals in the U.S. without health insurance between 1963–2015

Affordable Care Act provision

Prior to passage of the ACA, Medicaid did not extend general eligibility to low-income adults without child dependants,[5] though the federal government could authorize waivers for states to expand medicaid coverage;[6]: 2  by 2012, eight states provided full Medicaid benefits to this group.[7] The Medicaid statute also permitted states to cover some cohorts (termed "optional eligibiltiy groups") without a permit.[6]: 2  However, some states set stringent income eligibility thresholds well below the federal poverty level (FPL) for caretakers and parents of minors.[5] In line with its previous efforts to curtain the expansion of the State Children’s Health Insurance Program (SCHIP), the Bush administration imposed additional restrictions on states attempting to raise the income cap for Medicaid eligibility in 2008.[8] Healthcare reform was a key issue in campaigns for the 2008 United States presidential election.[9] A poll of delegates conducted by the New York Times and CBS News found that 94 percent of Democratic delegates viewed expanding healthcare coverage to all Americans as more important than lowering taxes, compared to 7 percent for Republican delegates.[10][11]

The ACA was signed into law in March 2010 by President Barack Obama after passing with narrow majorities in the House and Senate on nearly party lines.[12][13] Softening the eligibility requirements for Medicaid was a central goal of the ACA,[14] forming a two-pronged policy along with subsidized private insurance via health insurance marketplaces to expand health insurance coverage in the U.S.[15][7][3] The Medicaid expansion provision of the ACA allowed states to lower the income requirements for Medicaid eligibility, extending eligibility to non-pregnant adults under the age of 65 and not entitled to Medicare with incomes of up to 138 percent of the federal poverty level.[b][18][7] Within this cohort were three primary categories of adults: adults without dependent children, parents with dependent children, and adults with disabilities.[6] The ACA sought to eliminate categorical criteria barring these groups from Medicaid eligibility and standardize requirements across states.[19] The expansion provision also stipulated that the federal government would cover an enhanced share of the additional Medicaid expenditure incurred by states as a result of Medicaid expansion.[20][1] The expansion was to be enacted 2014, with the federal government funding 100 percent of states' costs through 2016 and then gradually declining its share stepwise to 90 percent in 2020 and onwards.[21][7] The ACA granted federal support to states classified as "expansion states" based on the following requirements:[22]: 273 

...a State is an expansion state if, on the date of the enactment of the Patient Protection and Affordable Care Act, the State offers health benefits coverage statewide to parents and nonpregnant, childless adults whose income is at least 100 percent of the poverty line, that is not dependent on access to employer coverage, employer contribution, or employment and is not limited to premium assistance, hospital-only benefits, a high deductible health plan, or alternative benefits under a demonstration program authorized under section 1938.

— 111th United States Congress, Patient Protection and Affordable Care Act

The Congressional Budget Office (CBO) estimated that Medicaid expansion under ACA as originally passed would cover 17 million uninsured Americans by 2022.[7] The newly-covered adult population in participating states were required to receive health coverage under an Alternative Benefit Plan (ABP) comparable or equivalent to either the state's traditional Medicaid package or a benchmark plan chosen by the state,[23][24] with mandatory coverage in ten categories of health benefits deemed essential by the ACA.[23] Those deemed medically frail would be given the option of choosing either the ABP or the traditional benefit package. The ABP would also cover screening and diagnostic and treatment services for enrollees younger than 21 years.[23] While Medicaid expansion was to come into force in 2014, the ACA also provided states the option to expand Medicaid early and receive matching funds from the federal government in raising the income cap for Medicaid as prescribed by ACA. States could also receive matching funds by expanding Medicaid early through other mechanisms and obtaining a Section 1115 waiver.[25]

National Federation of Independent Business v. Sebelius (2012)

Although Medicaid expansion under ACA was a de jure voluntary initiative for states, it was intended to be implemented nationally.[26] Opponents of the legislation described the conditioning of the increased funding for Medicaid on states opting into expansion as unconstitutionally coercive, making Medicaid expansion effectively mandatory.[26][23] The federal government typically covered only 50–83 percent of Medicaid costs prior to ACA,[26] with its share determined by the state's average per capita income.[23] The elevated share for Medicaid expansion implied over $500 billion in additional federal funding between 2014–2020.[26] In National Federation of Independent Business, the plaintiffs challenged the constitutionality of the ACA and contended that the Medicaid expansion provision was coercive. The U.S. District Court for the Northern District of Florida ruled in favor of the federal government on Medicaid expansion, and this ruling was upheld 2–1 in the U.S. Court of Appeals for the Eleventh Circuit.[27] While the Supreme Court largely upheld the constitutionality of the ACA, the court ruled in a 7–2 decision that the Medicaid expansion provision was unconstitutionally coercive.[5][27] The court established that the federal government could not condition funding for a preexisting program (i.e. Medicaid) on state participation in what the court classified as a new program (i.e. Medicaid expansion).[28] However, the court also ruled 5–4 that Medicaid expansion without the federal threat of defunding Medicaid in non-compliant states fell within the powers afforded by the Spending Clause to Congress.[27] Adoption of Medicaid expansion by individual states was effectively optional as a result of National Federation of Independent Business.[29] States opting out of Medicaid expansion could continue with their preexisting Medicaid requirements without the risk of federal defunding while states accepting the enhanced federal funding would be required to participate in Medicaid expansion.[30] In July 2012, the CBO revised its projection of Americans covered by Medicaid expansion by 2022 to 11 million as a result of the ruling.[7]

When the ACA fully came into effect in January 2014, 24 states and the District of Columbia adopted Medicaid expansion.[c][31] Most states implemented Medicaid expansion via expansion of their Medicaid programs while some states did so by other means such as the use of health savings accounts.[6] The incongruous adoption of Medicaid expansion was a result of several factors, including partisanship and pressure from private insurance stakeholders.[32][19] Primarily Republican resistance to Medicaid expansion prevented adoption of the provision in other states, with opponents characterizing expansion as an overreach of the federal government into a free market space and arguing that expansion would raise healthcare costs and lower coverage quality.[33] The American Rescue Plan Act of 2021, which passed in March 2021, compelled the federal government to cover an additional 5 percent of state expenditure incurred by Medicaid expansion atop the 90 percent stipulated by ACA to incentivize the then-12 non-expansion states to adopt Medicaid expansion, in addition to Missouri and Oklahoma which had adopted but not implemented expansion at the time.[34][35] As of March 2023, 40 states and the District of Columbia have adopted Medicaid expansion while 10 have not.[1]

See also

Notes

  1. ^ As of 2023, this corresponds to an annual income of $9,447 for parents in a family of three. In Texas, the state with the most stringent requirements, the income limit was $3,977 for parents in a family of three.[2]
  2. ^ As of 2023, this corresponds to an individual income of $20,120.[1] The statutory income requirement for Medicaid expansion was 133 percent and based on modified adjusted gross income (MAGI). Combining the 133 percent threshold with the statutory 5 percent income disregard under ACA results in a 138 percent effective income threshold.[16]: 1804 [17]: 11 
  3. ^ Arizona, California, Colorado, Connecticut, Delaware, Hawaii, Illinois, Iowa, Kentucky, Maryland, Massachusetts, Minnesota, Nevada, New Jersey, New York, North Dakota, Ohio, Rhode Island, Vermont, Washington, and West Virginia adopted Medicaid expansion concurrent with the enactment of the ACA on January 1, 2014.[1]

References

  1. ^ a b c d e f "Status of State Medicaid Expansion Decisions: Interactive Map". Medicaid. KFF. May 24, 2023. Retrieved May 24, 2023.
  2. ^ a b c d e Rudowitz, Robin; Drake, Patrick; Tolbert, Jennifer; Damico, Anthony (March 31, 2023). "How Many Uninsured Are in the Coverage Gap and How Many Could be Eligible if All States Adopted the Medicaid Expansion?". Medicaid. KFF. Archived from the original on May 25, 2023. Retrieved May 25, 2023.
  3. ^ a b Gunn, Dwyer (June 14, 2017) [January 26, 2016]. "The Medicaid Coverage Gap Persists". Pacific Standard. Grist. Retrieved May 25, 2023.
  4. ^ "The Medicaid Coverage Gap: State Fact Sheets". Center on Budget and Policy Priorities. Retrieved May 24, 2023.
  5. ^ a b c Rosenbaum, Sara; Westmoreland, Timothy M. (August 2012). "The Supreme Court's Surprising Decision On The Medicaid Expansion: How Will The Federal Government And States Proceed?". Health Affairs. 31 (8): 1663–1672. doi:10.1377/hlthaff.2012.0766.
  6. ^ a b c d Mitchell, Alison (December 30, 2014). "Medicaid: The Federal Medical Assistance Percentage (FMAP)" (PDF). Congressional Research Service. Retrieved May 24, 2023 – via Federation of American Scientists.
  7. ^ a b c d e f Musumeci, MaryBeth (August 2012). A Guide to the Supreme Court’s Decision on the ACA’s Medicaid Expansion (PDF) (Report). KFF. Retrieved May 25, 2023.
  8. ^ Pear, Robert (January 4, 2008). "U.S. Curtailing Bids to Expand Medicaid Rolls". New York Times. Retrieved May 25, 2023.
  9. ^ Lake, Celinda C.; Crittenden, Robert A.; Mermin, David (May 2008). "Health Care In The 2008 Election: Engaging The Voters". Health Affairs. 27 (3): 693–698. doi:10.1377/hlthaff.27.3.693.
  10. ^ Blendon, Robert J.; Altman, Drew E.; Benson, John M.; Brodie, Mollyann; Buhr, Tami; Deane, Claudia; Buscho, Sasha (November 6, 2008). "Voters and Health Reform in the 2008 Presidential Election". New England Journal of Medicine. 359 (19): 2050–2061. doi:10.1056/NEJMsr0807717.
  11. ^ Calmes, Jackie; Thee, Megan (August 31, 2008). "G.O.P. Rallies in Support of McCain, Poll Shows". New York Times. Retrieved May 25, 2023.
  12. ^ Haselswerdt, Jake (August 2017). "Expanding Medicaid, Expanding the Electorate: The Affordable Care Act's Short-Term Impact on Political Participation". Journal of Health Politics, Policy and Law. 42 (4): 667–695. doi:10.1215/03616878-3856107.
  13. ^ Jacobs, Lawrence R.; Callaghan, Timothy (October 2013). "Why States Expand Medicaid: Party, Resources, and History". Journal of Health Politics, Policy and Law. 38 (5): 1023–1050. doi:10.1215/03616878-2334889.
  14. ^ Mazurenko, Olena; Balio, Casey P.; Agarwal, Rajender; Carroll, Aaron E.; Menachemi, Nir (June 2018). "The Effects Of Medicaid Expansion Under The ACA: A Systematic Review". Health Affairs. 37 (6). doi:10.1377/hlthaff.2017.149.
  15. ^ Levitt, Larry (October 14, 2021). "The Inequity of the Medicaid Coverage Gap and Why It Is Hard to Fix It". JAMA Health Forum. 2 (10): e213905. doi:10.1001/jamahealthforum.2021.3905.
  16. ^ Wen, Hefei; Druss, Benjamin G.; Cummings, Janet R. (December 2015). "Effect of Medicaid Expansions on Health Insurance Coverage and Access to Care among Low-Income Adults with Behavioral Health Conditions". Health Services Research. 50 (6): 1787–1809. doi:10.1111/1475-6773.12411. PMC 4693853. PMID 26551430.
  17. ^ Gee, Emily R. (February 11, 2014). Eligible Uninsured Latinos: 8 in 10 Could Receive Health Insurance Marketplace Tax Credits, Medicaid or CHIP (PDF) (Report). Department of Health and Human Services. Retrieved May 24, 2023.
  18. ^ "Medicaid expansion". Glossary. Healthinsurance.org. Retrieved May 24, 2023.
  19. ^ a b Olson, Laura Katz (July 3, 2015). "The Affordable Care Act and the Politics of the Medicaid Expansion". New Political Science. 37 (3): 295–320. doi:10.1080/07393148.2015.1056428.
  20. ^ Petersen, Chris L. (April 7, 2010). "Medicaid: The Federal Medical Assistance Percentage (FMAP)" (PDF). Congressional Research Service. Retrieved May 24, 2023 – via EveryCRSReport.
  21. ^ Lyon, Sarah M.; Douglas, Ivor S.; Cooke, Colin R. (May 2014). "Medicaid Expansion under the Affordable Care Act. Implications for Insurance-related Disparities in Pulmonary, Critical Care, and Sleep". Annals of the American Thoracic Society. 11 (4): 661–667. doi:10.1513/AnnalsATS.201402-072PS. PMC 4225799. PMID 24708065.
  22. ^ The Patient Protection and Affordable Care Act (PDF) (111–143). 111th United States Congress. March 23, 2010. pp. 119–1024.
  23. ^ a b c d e Crowley, Ryan A.; Golden, William (March 18, 2014). "Health policy basics: Medicaid expansion". Annals of internal medicine. 160 (6): 423–5. doi:10.7326/M13-2626. PMID 24366475.
  24. ^ Andrews, Christina M.; Grogan, Colleen M.; Smith, Bikki Tran; Abraham, Amanda J.; Pollack, Harold A.; Humphreys, Keith; Westlake, Melissa A.; Friedmann, Peter D. (August 2018). "Medicaid Benefits For Addiction Treatment Expanded After Implementation Of The Affordable Care Act". Health Affairs. 37 (8): 1216–1222. doi:10.1377/hlthaff.2018.0272.
  25. ^ "States Getting a Jump Start on Health Reform's Medicaid Expansion". KFF. April 2, 2012. Retrieved May 25, 2023.
  26. ^ a b c d Pear, Robert (March 24, 2012). "Implications Are Far-Reaching in States' Challenge of Federal Health Care Law". New York Times. Retrieved May 25, 2023.
  27. ^ a b c "National Federation of Independent Business v. Sebelius". Oyez. Retrieved May 25, 2023.
  28. ^ Rosenbaum, Sara; Wilensky, Gail (March 2020). "Closing The Medicaid Coverage Gap: Options For Reform: A review of options that could make health insurance more affordable for 2.5 million poor working age adults who live in states that have not expanded Medicaid under the Affordable Care Act". Health Affairs. 39 (3): 514–518. doi:10.1377/hlthaff.2019.01463.
  29. ^ Garfield, Rachel; Damico, Anthony (October 2017). The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid (PDF) (Report). KFF. Retrieved May 25, 2023.
  30. ^ Russell, Kevin (June 28, 2012). "Court holds that states have choice whether to join medicaid expansion". SCOTUSblog. Retrieved May 25, 2023.
  31. ^ Escarce, José J.; Wozniak, Gregory D.; Tsipas, Stavros; Pane, Joseph D.; Ma, Yanlei; Brotherton, Sarah E.; Yu, Hao (May 2022). "The Affordable Care Act Medicaid Expansion, Social Disadvantage, and the Practice Location Choices of New General Internists". Medical Care. 60 (5): 342–350. doi:10.1097/MLR.0000000000001703. PMC 8989636. PMID 35250020.
  32. ^ Lanford, Daniel; Quadagno, Jill (September 2016). "Implementing ObamaCare: The Politics of Medicaid Expansion under the Affordable Care Act of 2010". Sociological Perspectives. 59 (3): 619–639. doi:10.1177/0731121415587605.
  33. ^ Neukam, Stephen (March 23, 2023). "These 10 states have not expanded Medicaid". The Hill. Nexstar Media. Retrieved May 25, 2023.
  34. ^ Musumeci, MaryBeth (March 18, 2021). "Medicaid Provisions in the American Rescue Plan Act". KFF. Retrieved May 26, 2023.
  35. ^ Rosenbaum, Sara; Handley, Morgan; Casoni, Maria; Morris, Rebecca (March 23, 2021). "Medicaid And The American Rescue Plan: How It All Fits Together". Health Affairs Blog. HealthAffairs. doi:10.1377/forefront.20210322.86077. Retrieved May 26, 2023.
Retrieved from "https://en.wikipedia.org/w/index.php?title=Medicaid_coverage_gap&oldid=1157923229"