The Troubled Future for State Medicaid Expansion

Shutterstock

 

Connecting state and local government leaders

The Affordable Care Act’s extension of public insurance to poor adults might finally make its way into every state. But those inroads could come with a cost.

In 2012, the Supreme Court’s decision in the NFIB v. Sebelius case sent shockwaves through the health-policy community, with Chief Justice John Roberts’s majority opinion causing much teeth-gnashing all around. Among many conservatives, the preservation of the Affordable Care Act’s individual mandate constituted “one of the worst Supreme Court decisions in American history.” For supporters of the law, the decision to turn the ACA’s expansion of Medicaid into a state-optional program threatened to destabilize the entire project of expanding coverage to the poorest Americans. For them, Roberts’s decision was, to borrow a phrase from The Atlantic’s first editor James Russell Lowell, “a good umbrella but a poor roof.”

In the five years since that decision, the worst predictions have yet to come true. Before its repeal last year, the individual mandate hadn’t become a springboard for more tax-enforced big-government reforms. And Obamacare hasn’t been undone by the optional Medicaid expansion.

The Court’s decision has, however, substantially altered the ability of the ACA to meet the affordability or access goals envisioned by its architects. Most states have chosen to expand the program, but others have held out instead, making the goal of gradual expansion of insurance to almost everyone impossible, at least in the foreseeable future. Through its sheer size and inertia, the biggest health reform in a half-century has become like most other American mega-policies: too big to truly collapse, but not quite ambitious enough to solve the problem.

At least, that was its state before Donald Trump entered the picture. Despite his promises to repeal the ACA, the president has taken steps that could effectively cement the expansion’s reach into every state. Several hardcore anti-Obamacare states now suddenly find themselves contemplating expansion, motivated by conservative reforms championed by Trump’s administration. Yet, paradoxically, if these reforms do help Medicaid expansion reach every state, they will almost certainly destroy the ability of health-insurance coverage to reach every person.

The peculiarity of this moment is evident in what states are suddenly eyeing Medicaid expansion, which offers health coverage to more low-income, able-bodied, non-elderly adults than the original program. It appears likely that Republican-dominated Utah will make a move at some point in the near future. The Virginia legislature is on the brink of approving some kind of framework for expansion on a bipartisan basis. Maine just recently expanded Medicaid, and similar ballot initiatives in Idaho and Nebraska might yield expansions, too. From top to bottom, even in the most conservative states, there seems to be more energy in the direction of expanding Medicaid than there has ever been.

But there’s also unprecedented energy for changing state Medicaid programs in some of those same conservative states, often in ways that tighten and restrict eligibility. As Vox notes, a dozen or more states are now applying for or considering federal-government waivers that would allow them to implement work requirements, time limits, or drug tests in their respective programs. Those include Republican-led states that have already expanded Medicaid, like Arizona, Indiana, Kentucky, Arkansas, and New Hampshire. The Centers for Medicare and Medicaid Services have already signed off on conservative-oriented waivers in those areas—including one for Arkansas’s “private option,” which provides able-bodied adults on Medicaid with coverage through private insurance plans.

The potential for the federal government to approve further conservative reforms, such as work requirements, was an important consideration in those states when choosing to expand their programs. And in January, CMS obliged, with Administrator Seema Verma agreeing to approve work requirements in state Medicaid waivers for the first time. The first state to have such a waiver approved was Kentucky, which—in addition to implementing the new work standards—assigned a premium structure to able-bodied adults’ plans, along with lockouts for those who don’t pay. CMS approved similar waivers from Indiana and Arkansas in February. (Some states, like Mississippi and Oklahoma, still aren’t considering an expansion of Medicaid, but they are weighing work requirements for the small population of able-bodied adults covered under their existing Medicaid programs.)

In some conservative states still without Medicaid expansion, lawmakers’ deliberation over work requirements will be critical to their ultimate decision. For example, the Utah House recently passed a bill approving a limited, eligibility-restricted Medicaid expansion with a work requirement in order to stave off pressure from a citizen-led ballot initiative that supports full expansion without any such restriction. The bill now sits before the state Senate.

Utah’s example is instructive, especially given the ongoing wave of pro-expansion ballot initiatives hitting conservative-leaning states. Maine Governor Paul LePage, a Republican, pushed back hard against an expansion initiative last fall, and even threatened not to implement the passed reform, which would have been a violation of state and federal law. Now, Maine is at the front of the queue seeking CMS approval for work requirements for its new expansion program. In the face of a petition to expand Medicaid in Nebraska, some state lawmakers have also suggested adding the restrictions. And with Idaho petitioners making headway on yet another ballot initiative, a plan to create a more limited expansion with work requirements is now circulating in the state legislature.

These states illustrate two trends. First, popular support for full expansion is growing—reflecting record-high public opinion for the ACA across the country—even among conservative voters and in conservative-leaning areas. That growing energy is manifesting in the bipartisan ballot initiatives and other campaigns that seek to circumvent GOP state legislators and governors, who often still oppose the measures. Second, facing the turning tide of public opinion, those GOP state leaders are choosing to stonewall or make expansion as restrictive as possible.

The latter course of action is gaining steam, with assistance from Verma. But the reforms, touted as maximizing states’ flexibility, have but one major outcome: They cover fewer people. The net effect of work requirements, premiums, and lockout periods will be fewer enrollees, and more people will be kicked off for failure to work or pay premiums.

With more and more states eyeing work requirements—and more conservative legislators considering them as mechanisms to get out in front of public opinion, while simultaneously constraining state programs—these reforms actually stand to short-circuit the ACA’s intent to give coverage to more people, even as they might prompt more states to get in the expansion game. Widespread eligibility restrictions could offset the benefits of providing greater access to care for low-income individuals, and set the stage for the creation of a limited, punitive Medicaid regime nationwide.

That appears to be the point. While appetite for full Obamacare repeal has died down, and CMS has recently accepted that the ACA is the law of the land, the push to tightly constrain Medicaid budgets and caseloads is only ramping up. The Trump administration’s strategy for Medicaid appears particularly Odyssean: By providing more states with the mechanisms to expand Medicaid, they also provide the ultimate tools for shrinking it.

Vann R. Newkirk II writes for The Atlantic, where this article was originally published.

FEATURED CASE STUDIES
Powered By The Atlas
Corpus Christi Deploys COVID Management System to Improve Data & Eliminate Time-Consuming Tasks
Corpus Christi, TX, USA
Safer Holiday Celebrations Connect Residents and Support Local Business in Franklin, TN
Franklin, TN, USA
Mobile-first Crisis Communications in Dublin, OH
Dublin, OH, USA

NEXT STORY: Medicaid Makes Up Largest Share of Grants to States

X
This website uses cookies to enhance user experience and to analyze performance and traffic on our website. We also share information about your use of our site with our social media, advertising and analytics partners. Learn More / Do Not Sell My Personal Information
Accept Cookies
X
Cookie Preferences Cookie List

Do Not Sell My Personal Information

When you visit our website, we store cookies on your browser to collect information. The information collected might relate to you, your preferences or your device, and is mostly used to make the site work as you expect it to and to provide a more personalized web experience. However, you can choose not to allow certain types of cookies, which may impact your experience of the site and the services we are able to offer. Click on the different category headings to find out more and change our default settings according to your preference. You cannot opt-out of our First Party Strictly Necessary Cookies as they are deployed in order to ensure the proper functioning of our website (such as prompting the cookie banner and remembering your settings, to log into your account, to redirect you when you log out, etc.). For more information about the First and Third Party Cookies used please follow this link.

Allow All Cookies

Manage Consent Preferences

Strictly Necessary Cookies - Always Active

We do not allow you to opt-out of our certain cookies, as they are necessary to ensure the proper functioning of our website (such as prompting our cookie banner and remembering your privacy choices) and/or to monitor site performance. These cookies are not used in a way that constitutes a “sale” of your data under the CCPA. You can set your browser to block or alert you about these cookies, but some parts of the site will not work as intended if you do so. You can usually find these settings in the Options or Preferences menu of your browser. Visit www.allaboutcookies.org to learn more.

Sale of Personal Data, Targeting & Social Media Cookies

Under the California Consumer Privacy Act, you have the right to opt-out of the sale of your personal information to third parties. These cookies collect information for analytics and to personalize your experience with targeted ads. You may exercise your right to opt out of the sale of personal information by using this toggle switch. If you opt out we will not be able to offer you personalised ads and will not hand over your personal information to any third parties. Additionally, you may contact our legal department for further clarification about your rights as a California consumer by using this Exercise My Rights link

If you have enabled privacy controls on your browser (such as a plugin), we have to take that as a valid request to opt-out. Therefore we would not be able to track your activity through the web. This may affect our ability to personalize ads according to your preferences.

Targeting cookies may be set through our site by our advertising partners. They may be used by those companies to build a profile of your interests and show you relevant adverts on other sites. They do not store directly personal information, but are based on uniquely identifying your browser and internet device. If you do not allow these cookies, you will experience less targeted advertising.

Social media cookies are set by a range of social media services that we have added to the site to enable you to share our content with your friends and networks. They are capable of tracking your browser across other sites and building up a profile of your interests. This may impact the content and messages you see on other websites you visit. If you do not allow these cookies you may not be able to use or see these sharing tools.

If you want to opt out of all of our lead reports and lists, please submit a privacy request at our Do Not Sell page.

Save Settings
Cookie Preferences Cookie List

Cookie List

A cookie is a small piece of data (text file) that a website – when visited by a user – asks your browser to store on your device in order to remember information about you, such as your language preference or login information. Those cookies are set by us and called first-party cookies. We also use third-party cookies – which are cookies from a domain different than the domain of the website you are visiting – for our advertising and marketing efforts. More specifically, we use cookies and other tracking technologies for the following purposes:

Strictly Necessary Cookies

We do not allow you to opt-out of our certain cookies, as they are necessary to ensure the proper functioning of our website (such as prompting our cookie banner and remembering your privacy choices) and/or to monitor site performance. These cookies are not used in a way that constitutes a “sale” of your data under the CCPA. You can set your browser to block or alert you about these cookies, but some parts of the site will not work as intended if you do so. You can usually find these settings in the Options or Preferences menu of your browser. Visit www.allaboutcookies.org to learn more.

Functional Cookies

We do not allow you to opt-out of our certain cookies, as they are necessary to ensure the proper functioning of our website (such as prompting our cookie banner and remembering your privacy choices) and/or to monitor site performance. These cookies are not used in a way that constitutes a “sale” of your data under the CCPA. You can set your browser to block or alert you about these cookies, but some parts of the site will not work as intended if you do so. You can usually find these settings in the Options or Preferences menu of your browser. Visit www.allaboutcookies.org to learn more.

Performance Cookies

We do not allow you to opt-out of our certain cookies, as they are necessary to ensure the proper functioning of our website (such as prompting our cookie banner and remembering your privacy choices) and/or to monitor site performance. These cookies are not used in a way that constitutes a “sale” of your data under the CCPA. You can set your browser to block or alert you about these cookies, but some parts of the site will not work as intended if you do so. You can usually find these settings in the Options or Preferences menu of your browser. Visit www.allaboutcookies.org to learn more.

Sale of Personal Data

We also use cookies to personalize your experience on our websites, including by determining the most relevant content and advertisements to show you, and to monitor site traffic and performance, so that we may improve our websites and your experience. You may opt out of our use of such cookies (and the associated “sale” of your Personal Information) by using this toggle switch. You will still see some advertising, regardless of your selection. Because we do not track you across different devices, browsers and GEMG properties, your selection will take effect only on this browser, this device and this website.

Social Media Cookies

We also use cookies to personalize your experience on our websites, including by determining the most relevant content and advertisements to show you, and to monitor site traffic and performance, so that we may improve our websites and your experience. You may opt out of our use of such cookies (and the associated “sale” of your Personal Information) by using this toggle switch. You will still see some advertising, regardless of your selection. Because we do not track you across different devices, browsers and GEMG properties, your selection will take effect only on this browser, this device and this website.

Targeting Cookies

We also use cookies to personalize your experience on our websites, including by determining the most relevant content and advertisements to show you, and to monitor site traffic and performance, so that we may improve our websites and your experience. You may opt out of our use of such cookies (and the associated “sale” of your Personal Information) by using this toggle switch. You will still see some advertising, regardless of your selection. Because we do not track you across different devices, browsers and GEMG properties, your selection will take effect only on this browser, this device and this website.