Medicaid Expansions

One of the major vehicles in the Affordable Care Act (ACA) to increase health insurance coverage is an expansion of Medicaid to adults with incomes at or below 138% of the federal poverty level (FPL). While the expansion was intended to be implemented in all states, as a result of the Supreme Court decision on the ACA, it is now effectively a state choice. Based on an analysis of 2011 American Community Survey data, this brief examines the implications of current state Medicaid expansion decisions on coverage by race and ethnicity.

This brief explores how state officials and stakeholders are analyzing the fiscal and macroeconomic implications of their choice about whether to expand Medicaid. It focuses on 10 of the 11 states that are participating in the Robert Wood Johnson Foundation’s (RWJF) health reform monitoring and tracking project. The discussion is divided into four sections: the legal and policy context in which states are deciding whether to expand Medicaid; the status of decision-making around Medicaid expansion in our 10 RWJF states; how the fiscal effects of Medicaid expansion are being analyzed; and how the macroeconomic effects of Medicaid expansion are being analyzed.

This chart tracks state Medicaid expansion decisions and includes additional details on key elements of Medicaid expansion bills that have been introduced in state legislatures, such as proposals to provide coverage to the expansion population through qualified health plans on the exchange, special requirements related to cost sharing or care delivery, or options allowing a state to discontinue participation in the expansion. This chart is a record of legislation introduced, but does not track the exact status of bills moving around in state legislatures.

An estimated 47 million Americans will transition at least once annually between Medicaid and subsidized health insurance exchanges starting next year. Only close collaboration between CMS and state exchanges will avoid interruption in insurance coverage and cost increases during these transitions. In her updated Health Reform GPS implementation brief, George Washington University's Sara Rosenbaum reviews FAQs recently issued by CMS that address issues related to Medicaid/Exchange alignment.

Since US Supreme Court’s ruling on the ACA that allowed states to opt out of the health reform law’s Medicaid expansion, fourteen governors have announced that their states will not expand their Medicaid programs. This paper’s authors used the RAND COMPARE microsimulation to analyze how opting out of Medicaid expansion would affect coverage and spending, and whether alternative policy options—such as partial expansion of Medicaid—could cover as many people at lower costs to states. They concluded that in terms of coverage, cost, and federal payments, states would do best to expand Medicaid.

The ACA specifies a standard definition of income – Modified Adjusted Gross Income (MAGI) – that will be used to determine eligibility for both Medicaid and the Exchange-based premium tax credits and cost-sharing reductions. The adoption of MAGI creates a number of issues for states, particularly when applying MAGI to eligibility determination for Medicaid. In this brief, the author reviews the income that is included in MAGI and how income is currently counted in determining Medicaid eligibility. Issues related to measuring MAGI on a monthly basis for Medicaid eligibility determination are discussed, and the author offers some thoughts on how states might begin to address these issues in their application of MAGI to determine eligibility for Medicaid.

This brief examines the cost and use of health care among low-income nonelderly adults who are covered by Medicaid relative to their expected service use and costs if they instead had employer-sponsored insurance coverage or were uninsured. The analysis controls for a wide array of factors that also influence utilization and spending in an effort to isolate the specific effects of Medicaid coverage. Consistent with previous research, the analysis underscores how Medicaid facilitates access to care for program beneficiaries.

States expanding Medicaid eligibility under the ACA can substantially expedite Medicaid enrollment and retention for SNAP participants, 97 percent of whom will qualify for Medicaid, according to this study. Even in states where SNAP provides broad-based categorical eligibility that extends SNAP’s gross income limits to at least 185 percent of the federal poverty level, 94 percent of SNAP recipients will qualify for Medicaid. Data showing SNAP receipt can thus verify Medicaid applicants’ financial eligibility, allow administrative renewal for Medicaid beneficiaries, and facilitate Medicaid enrollment for numerous eligible consumers when expanded coverage begins in early 2014.

Medicaid provides critical health insurance coverage to tens of millions of children, adults, elderly and people with disabilities every year. Under the Affordable Care Act (ACA), millions more will gain Medicaid coverage, beginning in 2014. However, Medicaid can be like a leaky sieve: every year millions of people enroll, only to subsequently lose their coverage, even though they are still eligible, due to cumbersome paperwork requirements and small, often short-term, increases in income. The problem of beneficiaries entering and exiting Medicaid is sometimes called “churning.” This report examines the impact of churning in every state.

With changes to Medicaid eligibility going into effect in January 2014, CMS has issued a letter detailing five targeted enrollment strategies that can help states with the transition to their new eligibility and enrollment systems.