Gamechanger: Medicaid Expansion in Low-Income Populations

Background

Since it was signed into law in 2010, the Patient Protection and Affordable Care Act has been the subject of much political controversy. One polarizing provision of the Affordable Care Act (ACA) is the expansion of Medicaid. Though Medicaid expansion was passed federally,  the adoption of the expansion remains at the discretion of each state. Today, 31 states have adopted Medicaid expansion while 20 states have either not expanded or are still debating the issue.  

Under current federal regulations, states must provide Medicaid coverage for children younger than 6 years of age with family income up to 133% of the federal poverty level, children ages 6 to 18 years with family income at or less than 100% of the federal poverty level, pregnant women, and low-income elderly persons (Kaiser Family Foundation). The ACA (1) expanded Medicare eligibility to uninsured, non-disabled adults without children whose family income is at or below 138% of the federal poverty level and (2) established state health insurance exchange programs that offer a variety of low-cost options for enrollment with variable benefit packages (Chesney, 313). These new provisions are projected to result in insurance coverage for 33 million uninsured people by 2022.

why expansion matters: Medicaid and access to care

"Medicaid is the largest provider of health insurance for children and adults in the United States and provides critical financial support for the nation's safety net clinics, hospitals, and long-term care facilities that serve the poor and underserved." 
- Mary Chesney, PhD, RN, CPNP


Medicaid is the nation's largest provider of health insurance for children and adults. It insures over 65 million Americans, provides financial support for the nation's safety net institutions, and is central to increasing access to care for many of the most disadvantaged individuals and families in the United States.

Medicaid expansion significantly impacts access to care, health outcomes, and quality of care in vulnerable populations. Thirty-one million children (one in three) and more than 60% of residents in nursing homes depend on Medicaid to receive health care services (Center on Budget and Policy Priorities).  Health insurance coverage is associated with better health outcomes because it grants individuals regular access to care and fosters greater and more appropriate use of health services. These factors, in turn, improve the likelihood of disease screening and early detection, the management of chronic illness, and effective treatment of acute conditions such as traumatic brain injury and heart attacks (Kaiser). Therefore, the ultimate result of Medicaid expansion is better health outcomes.

setting the landscape: medicaid expansion by state

Though the benefits of Medicaid expansion are well documented, states have taken variable approaches to ACA Medicaid Expansion. A recent study examined ACA-related experiences among low-income adults in three states with markedly different ACA policies: Arkansas, Kentucky, and Texas (Sommers, 1010). The objective of the study was to assess the experiences of low-income adults in each of the three states and explore connections between state policy and enrollment in low-income populations.

The Medicaid expansion policies of Kentucky, Arkansas, and Texas are compared in the table below.

State	Medicaid Expansion Adopted?	State Marketplace?	Outreach Efforts?
Kentucky	Yes, traditional Medicaid expansion	Yes	Yes, aggressive outreach by governor’s office, navigators, and in-person assisters
Arkansas	Yes, private option	Yes, federal-state partnership Marketplace	Yes, in-person assistance only; ACA promotion strictly prohibited
Texas	No	No	No, ACA promotion and use of navigators are strictly restricted

Because of their disparate policies, Kentucky, Arkansas, and Texas have seen different results regarding ACA applications and enrollment among low-income adults. Study results indicate that low-income adults in Kentucky - and to a lesser extent in Arkansas- are much more likely to apply and enroll in Medicaid or other Marketplace plans than low-income adults in Texas (Sommers, 1011). These results reinforce the importance of accessible care in granting health insurance to those who need it the most.

The high accessibility and promotion of Medicare and the Marketplace has created a 52% decrease in the number of uninsured Kentuckians since 2013 (Duckett). According to a report published by the Kentucky Cabinet for Health and Family Services, 75% of Kentuckians who had signed up for coverage during the 2014 open enrollment session (391,000 Kentuckians) indicated that they had been uninsured prior to gaining insurance through the state exchange.

final take-aways

Kentucky's success with ACA applications and enrollment is accredited to the state's adoption of the Medicaid expansion, the commission of a state marketplace, and aggressive outreach efforts that used a mix of the governor's office, in-person assistance, and navigators to assist applicants throughout the enrollment process. Similar measures in other states (Maryland, West Virginia, etc.) have also seen positive results. In contrast, states such as Texas who have restricted ACA expansion efforts have seen markedly less progress regarding declines in the uninsured population (17% in Texas compared to over 50% in Kentucky, Maryland, and West Virginia).

This unprecedented coverage is especially significant for those who previously did not qualify for Medicaid but could not afford private insurance. Through the expansion, individuals who fall in this coverage gap are granted access to Medicaid or low-cost private insurance plans that can save their lives in the long run.As a result, one can infer that the best way for states to improve access to care for low-income populations is to adopt Medicaid expansion. The expansion of these provisions will increase access to care, foster positive health outcomes, and help push disadvantaged populations toward health equity. 

sources

Chesney, Mary. "Affordable Care Act: Medicaid Expansion Key to Increasing Access to Care." Journal of Pediatric Health Care 27 (2013): 312-15. Web.

Duckett, Philethea, Artiga, Samantha. "Health Coverage for the Black Population Today and Under the Affordable Care Act." Kaiser Family Foundation (2013). Web.

Paradise, Julia. "Medicaid Moving Forward." Kaiser Family Foundation (2015). Web.

Sommers, B. D., B. Maylone, K. H. Nguyen, R. J. Blendon, and A. M. Epstein. "The Impact Of State Policies On ACA Applications And Enrollment Among Low-Income Adults In Arkansas, Kentucky, And Texas." Health Affairs 34.6 (2015): 1010-018. Web.