Health Care and Medicaid

One of the most difficult health care issues facing America today is Medicaid, the state run public healthcare assistance program for people who are poor. The technical description of Medicaid is that is a federal program that provides health coverage to nearly 60 million children, families, pregnant women, the elderly, and people with disabilities, and it is administered at the state level. Medicaid covers US citizens and eligible immigrants.

All States provide Medicaid to infants and children under age 6 with family incomes up to 133% of the federal poverty level, or FPL. Medicaid is available in every state for children under age 19 with family incomes up to 100% of the FPL. For a family or household of 4 persons living in one of the 48 contiguous states or the District of Columbia, the poverty guideline for 2015 is $33,465 if your state is expanding Medicaid. Separate poverty guideline figures are developed for Alaska and Hawaii, and different guidelines may apply to the Territories.

Medicaid pays for a full set of services for children, including preventive care, immunizations, screening and treatment of health conditions, doctor and hospital visits, and vision and dental care. In most cases, these services are provided at no cost to families.

Medicaid is the largest source of funding for medical and health-related services for people with low income in the United States. It is a means-tested program that is jointly funded by the state and federal governments and managed by the states, with each state currently having broad leeway to determine who is eligible for its implementation of the program, according to CMS, the Centers for Medicare and Medicaid Services.

States are not required to participate in the program, although all currently do. Medicaid recipients must be U.S. citizens or legal permanent residents, and may include low-income adults, their children, and people with certain disabilities. Poverty alone does not necessarily qualify someone for Medicaid.

The Patient Protection and Affordable Care Act significantly expanded both eligibility for and federal funding of Medicaid. Under the law as written, all U.S. citizens and legal residents with income up to 133% of the poverty line, including adults without dependent children, would qualify for coverage in any state that participated in the Medicaid program.

However, the United States Supreme Court ruled in National Federation of Independent Business v. Sebelius that states do not have to agree to this expansion in order to continue to receive previously established levels of Medicaid funding, and many states have chosen to continue with pre-ACA funding levels and eligibility standards.

According to the Kaiser Family Foundation (KFF), Medicaid is the nation’s main public health insurance program for people with low income and the single largest source of public health coverage in the U.S. covering nearly 70 million Americans. States design and administer their own Medicaid programs within federal requirements, and states and the federal government finance the program jointly. Medicaid plays many roles in our health care system.

Medicaid coverage facilitates access to care for beneficiaries, covering a wide range of benefits and tightly limiting out-of-pocket costs for care. As a major payer, Medicaid is a core source of financing for safety-net hospitals and health centers that serve low-income communities, including many of the uninsured. It is also the main source of coverage and financing for both nursing home and community-based long-term care. Altogether, Medicaid finances 16% of total personal health spending in the U.S.

There are, of course, a number of arguments against expanding Medicaid, according to the Atlantic Magazine. While the federal government would pick up much of the immediate cost of the new enrollees, it sticks states with 10 percent of the tab after 2020. A 2014 study found that people use emergency rooms more, not less, once they enroll in Medicaid, somewhat undermining the argument that the expansion would funnel more people toward cheaper primary-care doctors. (Though it’s worth noting that people tend to use all sorts of healthcare more — not just ERs —once they get insured.) And physicians are indeed reluctant to accept Medicaid: Its lower reimbursement rates mean that more than a third of doctors won’t see new Medicaid patients, a shortage that is especially acute among specialists.

Studies on Medicaid’s health benefits show mixed results. One Urban Institute paper found that Medicaid provides its beneficiaries with similar access to care as employer-sponsored insurance, except at a lower cost for the individual. For example, patients would spend more than four times as much on out-of-pocket medical expenses if they were uninsured, and three times as much if they had employer insurance, as they do with Medicaid.

Meanwhile, another New England Journal of Medicine (NEJM) study that looked at Oregon residents who won a Medicaid lottery found that getting coverage generated no significant improvements in cholesterol or hypertension in the first two years. It did, however, encourage people to go to the doctor more, raised their rates of diabetes detection and management, lowered rates of depression, and reduced financial strain. A NEJM study also found that states that had previously expanded Medicaid saw a 6.1 percent reduction in the death rate among adults younger than 65. While critics of Medicaid point out the program’s spotty record of saving money or alleviating certain health conditions, its proponents say that many of its shortcomings apply to Medicare and private insurance as well.

According to KFF, as of March 2015, 22 states were not expanding their programs. Medicaid eligibility for adults in states not expanding their programs is quite limited: the median income limit for parents in 2015 is just 44% of poverty, or an annual income of $8,840 a year for a family of three, and in nearly all states not expanding, childless adults will remain ineligible.

Further, because the ACA envisioned low-income people receiving coverage through Medicaid, it does not provide financial assistance to people below poverty for other coverage options. As a result, in states that do not expand Medicaid, many adults will fall into a “coverage gap” of having incomes above Medicaid eligibility limits but below the lower limit for Marketplace premium tax credits.

Nationally, nearly four million poor uninsured adults fall into the “coverage gap” that results from state decisions not to expand Medicaid, meaning their income is above current Medicaid eligibility but below the lower limit for Marketplace premium tax credits. These individuals would have been newly-eligible for Medicaid had their state chosen to expand coverage. Nationally, 43% of uninsured adults in the coverage gap are White non-Hispanics, 24% are Hispanic, and 27% are Black.

The ACA Medicaid expansion was designed to address the high uninsured rates among adults living below poverty, providing a coverage option for people who had limited access to employer coverage and limited income to purchase coverage on their own. However, with many states opting not to implement the Medicaid expansion, millions of adults will remain outside the reach of the ACA and continue to have limited, if any, options for health coverage: they are ineligible for publicly-financed coverage in their state, most do not have access to employer-based coverage through a job, and all have limited income available to purchase coverage on their own. A significant amount of info on Medicaid can be found at this site: http://kff.org/health-reform/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid-an-update/ .

Medicaid is a very expensive program to maintain and administer. And, at some future date, there is a tipping point where it won’t be sustainable or a viable option for states or the federal government. Not to mention, physician drop out in Medicaid is increasing at a greater rate since the Affordable Care Act negotiated reimbursements in the past few years.

What are the options? Charitable organizations are one option, and they are going to need to increase their work in communities affected by the lack of income based families who can afford insurance. Another option would be to engage individuals in financial counseling and income opportunities. States should develop programs to assist those adults capable of working to find better employment options, and educational programs should be developed in partnership with community organizations to provide job skills and training.

Although Medicaid is a way to help families and individuals receive a limited form of health care, it is not the end all answer. More work needs to be done by all stakeholders to improve the financial wellness of those with limited incomes to move beyond the FPL, and to encourage the health care community to lessen access the restrictions to all types of medical care. Certainly, Medicaid should be seen more as a stop gap measure versus the lifestyle it perpetuates.

Until next time.