ACA and Medicaid

VII. Key Issues: Regulation & Reform >> C. Health Reform >> Affordable Care Act (ACA) >> ACA and Government >> ACA and the States >> ACA and Medicaid (last updated 1.15.23)

Overview

As of January 4, 2019, Kaiser Family Foundation reported that 37 states including Washington, D.C., had adopted the Medicaid expansion allowed by the ACA and 14 States had not adopted the expansion.
Coverage under the Medicaid expansion became effective January 1, 2014, in all states that have adopted the Medicaid expansion except for the following: Michigan (4/1/2014), New Hampshire (8/15/2014), Pennsylvania (1/1/2015), Indiana (2/1/2015), Alaska (9/1/2015), Montana (1/1/2016), Louisiana (7/1/2016), Virginia (1/1/2019), and Idaho, Maine, Nebraska, and Utah (to be determined).
As of November 2018, Medicaid expansion had added 16.1 million net additional enrollees when compared to the number enrolled in the 3rd quarter of 2013. Enrollment is thought to have declined due to tapering ACA-related enrollment and improving economic conditions.
Medicaid gains accounted for 97% of the net reduction in uninsured in 2014. States that expanded Medicaid saw larger gains in coverage than the states that did not.
In June, 2018, about 2.6 million uninsured poor individuals were said to have fallen into a “coverage gap” — being too poor to qualify for tax credits but ineligible for Medicaid in nonexpansion states

Enrollment

Enrollment Data

  • CMS, November, 2018. 72,658,984 individuals were enrolled in Medicaid and CHIP in the 51 states (including Washington, D.C.) that reported enrollment data for November 2018. Medicaid enrollment dropped by approximately 1.82 million since December, 2017.
    • 66,067,254 individuals were enrolled in Medicaid.
    • 6,591,730 individuals were enrolled in CHIP.
  • CMS, December, 2017. Medicaid enrollment had increased by 17.6 million through December 2017, with total enrollment of 74.48 million.
  • Congressional Budget Office. The Budget and Economic Outlook: 2017 to 2027 (January, 2017). “By CBO’s estimates, an average of 12 million noninstitutionalized residents of the United States under age 65 will have health insurance in any given month in calendar year 2017 because they were made eligible for Medicaid under the ACA. That expanded eligibility for Medicaid applies principally to adults whose income is up to 138 percent of the federal poverty guidelines; the federal government pays nearly all of the costs of expanding Medicaid coverage to those new enrollees. On average, 17 million people are projected to have such coverage in 2027, if current laws remained in place.”
  • CMS Monthly Enrollment Data. Since October 2013, CMS has issued monthly reports on Medicaid and CHIP enrollment typically released with a 2-month delay. It issues a preliminary report downloadable as a Zip file and then the next month issues an updated version in pdf that provides official final totals. All of these reports can be found on this page. In February 2014, states were asked to provide enrollment data for a baseline period running from July through September 2013. The number of newly enrolled is calculated as the difference between the figure reported for the current month and the average monthly figure during the baseline period.
  • 17.3 Million Newly Enrolled.
    • The November 2016 report, Medicaid & CHIP: November 2016 Monthly Applications, Eligibility Determinations and Enrollment Report, is the latest released. Looking at the additional enrollment since October 2013 when the initial Marketplace open enrollment period began, among the 49 states reporting both November 2016 enrollment data and data from July-September of 2013, over 16.4 million additional individuals are enrolled in Medicaid and CHIP as of November 2016, almost a 29% increase over the average monthly enrollment for July through September of 2013 (Connecticut and Maine are not included in this count).
    • Charles Gaba at ACASignups estimates there were 950,000 additional Medicaid enrollees from seven states that implemented an “early option” to expand Medicaid coverage to adults with incomes up to 133 percent of the Federal Poverty Line (FPL) between April 1, 2010 and January 1, 2014.
    • The October 2016 CMS report had estimated a net gain of 16,954,476 enrollees compared to the baseline, i.e., 550,000 more than the preliminary November report. Based on this total, Charles Gaba estimates that the net increase in Medicaid enrollment can be broken down roughly as follows:
      • 12.3 million: ACA expansion specifically (across 31 states + DC)
      • 1.0 million (i.e., 950,000): Other ACA provisions (across 7 states)
      • 3.6 million (?): “Woodworkers” who were already eligible for traditional Medicaid/CHIP prior to the ACA but didn’t enroll until after the expansion started
      • 1.0 million (?): Newly eligible for traditional Medicaid/CHIP regardless of the ACA
  • Enrollment Greatly Exceeded Estimates of Potential Eligibles. In a study for Kentucky, Deloitte Consulting compared actual 2014 Medicaid enrollment to estimates of  potential enrollees, i.e., the total number of persons below 138% of poverty from the 2010 Census Bureau’s Small Area Health Insurance Estimates. In Medicaid expansion states actual enrollment exceeded potential enrollment by as little as 24% (HI) to as much as 596% (VT) (Table 25). 
  • Number Previously Uninsured. CMS does not report how many newly enrolled in Medicaid were previously uninsured. However, Heritage Foundation researchers calculate that for calendar year 2014, 97% of the reduction in uninsured (9.25 million) came from gains in Medicaid coverage (8.99 million). Using the 10.91 million figure below, this implies that 82.4% of Medicaid enrollees were previously uninsured.
    • The CMS enrollment report for December 2014 states: “among the 49 states reporting both December 2014 enrollment data and data from July-September of 2013, over 10.75 million additional individuals are enrolled in Medicaid and CHIP as of December 2014, approximately an 18.6 percent increase over the average monthly enrollment for July through September of 2013” (excludes CT and ME).
    • Total Medicaid/CHIP enrollment in December 2014 was 760,584 in CT and 287,087 in ME (Table 2); assuming the same 18.6% increase, we can impute that enrollment grew by 164,306 in these 2 states, making the total gain in coverage 10.91 million.
  • Uninsured Poor Coverage Gap. In the states that elected not to adopt the Medicaid expansion, Kaiser Family Foundation estimated (October, 2016) that there were 2.6 million uninsured people below poverty who hypothetically could have qualified for Medicaid coverage (90% of these are located in the South).
  • Millions Poised to Move Off Medicaid After Omnibus Bill Passage.“Millions of people are poised to lose Medicaid coverage after the recently enacted omnibus spending bill changed the healthcare program’s enrollment rules, and congressional Democrats and the Biden administration are working to steer eligible people to other types of coverage. The coverage losses are expected because states that received extra Medicaid funding under a 2020 Covid-19 relief bill had to agree to pause beneficiaries’ eligibility verifications. The continuous enrollment in the state-federal program for the low income and disabled was set to end when the health emergency is over, likely sometime in 2023. Instead, under a $1.65 trillion federal spending bill approved by Congress last week, states can begin disenrolling people from Medicaid in April even if the public-health emergency designation remains in place. Many of those who will lose coverage are likely to qualify for coverage under the Affordable Care Act, according to public-health officials and advocates.” (Wall Street Journal, 12.25.22)

Enrollment Trends

  • The ObamaCare Expansion Enrollment Explosion. “Numerous states that have adopted ObamaCare’s Medicaid expansion have seen enrollment in the welfare program far surpass initial projections. In fact, in many states, more able-bodied adults have signed up for the Medicaid expansion than officials thought would ever be eligible. (Foundation for Government Accountability, 4.20.15)
    • Colorado: [F]ar more able-bodied adults signed up for Medicaid expansion than state budgeters ever expected. The Colorado Department of Health Care Policy and Financing was unable to provide December 2014 enrollment figures for its Medicaid expansion, but according to federal data, Medicaid expansion enrollment had already reached 210,013 by March 2014.  Other case load reports indicate enrollment had grown to at least 307,333 by the end of 2014. 
    • Michigan: Despite the fact that Michigan did not expand Medicaid eligibility until April, nearly 508,000 adults signed up by the end of 2014, far more than the state thought would ever enroll. Enrollment continues to climb, with nearly 582,000 able-bodied adults signing up by April 2015.
    • Washington: Washington began exceeding those projections in February 2014, just two months into the expansion. By December, ObamaCare expansion enrollment swelled to nearly 510,000 adults, more than twice what was expected.41 The state has been forced to revise its Medicaid expansion budget projections five times, the most recent revision occurring in February 2015.  But even these revised projections are continually exceeded. Washington began exceeding the revised fiscal year 2017 projections shortly after they were completed in February 2015. 
    • West Virginia: West Virginia exceeded that first-year projection after a single month and began exceeding the maximum projected enrollment within three months. By September 2014, nearly 151,000 able-bodied adults had signed up for ObamaCare expansion. More adults likely signed up in the following months, leading to even larger cost overruns.” 
    • Also see Cost by State for more enrollment trends.
  • As of early March 2014, it was expected that roughly 8 million additional people would enroll in Medicaid, down from an estimate of 13 million people in 2014 made a few months before the June 2012 Supreme Court ruling.
  • HHS: As of October 17, 2014, “approximately 8.7 million additional Americans now have coverage through Medicaid and CHIP, many for the very first time.  Medicaid enrollment grew to more than 67.9 million in August 2014, which shows nearly a 15 percent increase over the average monthly enrollment for July through September 2013.”
  • Skyrocketing Medicaid Signups Stir Obamacare Fights. “More than 12 million people have signed up for Medicaid under the Affordable Care Act since January 2014, and in some states that embraced that piece of the law, enrollment is hundreds of thousands beyond initial projections. Seven states have seen particularly big surges, with their overruns totaling nearly 1.4 million low-income adults… In Michigan, where the first-year enrollment projection was 323,000 people, sign-ups hit 605,000 before falling back to 582,000 earlier this month. Kentucky signed up nearly 311,000 new adults by the end of its 2014 fiscal year, more than double its initial projection of 148,000. And in February 2014, Minnesota forecast that 147,000 newly eligible adults would enroll by December, but actual enrollment that month was at nearly 194,000.” (Politico, 5.18.15)
  • Medicaid Enrollment Under ObamaCare Soars, Raising Cost Concerns. “In Illinois, more than 540,000 people have enrolled under the Medicaid expansion, nearly 342,000 more than projected for the first year, according to state records. In Washington state, roughly 530,000 adults have enrolled in Apple Health Medicaid, more than double the 245,000 projected in 2012, which has increased total enrollment in the state program to 1.8 million, a state official told FoxNews.com. Kentucky estimated that 161,055 newly eligible residents would enroll in the Medicaid expansion by June 30, and enrollment is already at roughly 375,000, according to state records. Colorado, Maryland, Michigan and Ohio also have reported enrollment exceeded projections. At least seven of the 29 states (and the District of Columbia) that expanded coverage have experienced significantly higher-than-expected enrollment. The expansion of Medicaid, the government health care program for low-income people, now allows most low-income adults making up to 138 percent of the federal poverty level to qualify. An estimated 1.4 million more people than expected have signed up in those seven states since enrollment opened in October 2013 — with Illinois, Kentucky and Washington state more than doubling their projected numbers.” (Fox News, 6.8.15)
  • Obamacare’s Medicaid Enrollment Explosion: A Looming Fiscal Nightmare For States. “The Foundation for Government Accountability analyzed Medicaid expansion enrollment for 17 states. The remaining expansion states were excluded because they did not produce publicly available enrollment projections, expanded Medicaid eligibility prior to Obamacare, or refused to provide enrollment projections and/or actual enrollment data in response to public records requests. Of the 17 reviewed states, every single one far surpassed projected enrollment in 2014. In fact, these states surpassed projections by an average of 91%. But the news gets worse for state budgeters, as 2017 quickly approaches: each of these states have also surpassed their projected maximum enrollment. And these states didn’t just slightly exceed projections – they blew past them, by an average of 73%.” (Forbes, 7.30.15)
  • CBO: The Budget and Economic Outlook: 2016 to 2026 (January 2016). “The average number of people enrolled in Medicaid on a monthly basis is expected to rise from 76 million in 2015 to 77 million in 2016. By 2026, 80 percent of the people who meet the new eligibility criteria will live in states that have extended Medicaid coverage, CBO anticipates; Medicaid enrollment in that year is projected to be 85 million.”
  • Montana Underestimated Medicaid Expansion ‘Woodwork Effect.’ “The State of Montana underestimated the number of newly and previously eligible individuals who would sign up for its expanded Medicaid program under the Health and Economic Livelihood Partnership Act (HELP), which will now cost much more than predicted. Blue Cross Blue Shield, the program’s administrator, predicted 18,600 residents would enroll in Medicaid by January 1, 2016, the day the program’s expansion under the Affordable Care Act (ACA) took effect. Gov. Steve Bullock’s (D) administration estimated 23,000 would enroll by June 2016, according to a report by KRTV in Montana. On February 8, Bullock said more than 27,000 Montanans had enrolled, reports the Great Falls Tribune… Brent Mead, the executive director of the Montana Policy Institute, says the greater-than-expected enrollment numbers will significantly increase the cost of the state’s Medicaid expansion. ‘The total number of projected enrollees [was] around 22,700 for expansion and 800 woodwork enrollees,’ Mead said.” (Heartlander Magazine, 3.10.16)
  • Obamacare is Doing Way More to Help the Poor Than Anyone Expected. “Last year, CBO estimated that an average of 14 million low-income Americans would rely on the Medicaid expansion for coverage over the next decade. Now the forecasting agency expects that the program will have an average enrollment of 18 million. More Medicaid enrollees means more federal spending; the additional 4 million Medicaid patients are expected to drive up the cost of the insurance expansion by $146 billion… The Medicaid program is operating in significantly fewer states, but covering millions more people.” (Vox, 3.24.16) 
  • Medicaid Enrollment Declines for the First time in More than a Decade as Strong US Economy Boosts Income for Poor Americans. “Medicaid enrollment fell for the first time since 2007, declining by about 0.6 percent in fiscal year 2018, and states don’t expect to see much growth in enrollment next year, according to a Kaiser Family Foundation report released Thursday. States are budgeting for a ‘minimal’ increase of 0.9 percent in 2019, Kaiser said in its annual 50-state survey of Medicaid. ‘States largely attribute the enrollment slowdown to a strengthening economy, resulting in fewer new low-income people qualifying for Medicaid,’ said Kaiser, a nonprofit group that focuses on health care and health policy. Federal and state Medicaid spending still grew despite the drop in enrollment. Combined federal and state spending rose by 4.2 percent in fiscal 2018, similar to the previous year’s increase, Kaiser said. States expect a 5.3 percent jump in spending for 2019.” (CNBC, 10.25.18)

Fraudulent Enrollment

  • Arkansas Eligibility Issues. “In 2014, the Arkansas Department of Human Services removed nearly 5,000 Medicaid expansion enrollees, representing approximately three percent of enrollment, after learning they were ineligible for benefits. The state had not bothered to verify those applicants’ eligibility before enrolling them in Medicaid. In fact, some enrollees were receiving both Medicaid and federal ObamaCare subsidies. An earlier audit found more than 12 percent of individuals in higher-cost Medicaid cases were ineligible for the program. Another 24 percent lacked appropriate documentation to establish eligibility.” (Ribali, K, 2.10.16)
  • 80,000 Ineligible ACA Enrollees Cost Minnesota Millions “A report by Minnesota’s Office of the Legislative Auditor released last month, found that more than 80,000 Minnesotans were enrolled in Medicaid, and the state’s Obamacare exchange even though they were ineligible for the services. That incredible number of ineligible enrollees cost Minnesota taxpayers hundreds of millions of dollars. The problems apparently stem from ‘miscommunication and poor training at the Department of Human Services.’ However, the audit found that ‘software issues’ are were also blamed for the errors… The state used this study to estimate ‘that between 57,000 and 108,000 people received Medicaid or MinnesotaCare benefits but shouldn’t have received any benefits at all’… Auditors concluded that the ineligible recipients cost taxpayers somewhere between $115 million and $271 million.” (Ribali, K, 2.10.16)
  • Nebraska Eligibility Issues. “An audit in 2013 of the Nebraska Health Insurance Premium Payment (HIPP) program—a component of the state’s Medicaid program—found that the state lacked appropriate documentation in every reviewed case file, calling into question the entirety of expenditures made under the program. More than three-quarters of the audited cases had received incorrect payments, with auditors identifying several cases of apparent fraud. One individual, for example, received more than $29,000 from the Medicaid program despite being clearly ineligible for the HIPP program. In all, state auditors found that at least a quarter of all audited expenditures were improper.”  (Ribali, K, 2.10.16)
  • New York Eligibility Issues. “A 2006 federal audit found that eight percent of New York’s Medicaid payments were made on behalf of individuals who were ineligible, but nevertheless enrolled in the program. Approximately 29 percent of payments were made on behalf of enrollees whose case files did not contain the required documentation supporting their eligibility determinations. A follow-up audit in 2013 found a significant number of cases for which case files had missing or invalid Social Security numbers, individuals were enrolled in the same program multiple times, or the files lacked any documentation to support the eligibility determination at all.”  (Ribali, K, 2.10.16)
  • Ohio Eligibility Issues. “A state and federal review of Ohio’s Medicaid spending in 2008 found that nearly 10 percent of Medicaid payments were improper. Nearly all of these improper payments were caused by errors and insufficient documentation in eligibility determinations. Auditors also found a payment error rate of roughly 20 percent for Ohio’s TANF cash assistance program, caused primarily by eligibility and documentation errors. Nearly seven percent of audited payments went to individuals who were ineligible for the TANF program, while more than 13 percent went to individuals whose case files were missing the documentation required to establish eligibility.”  (Ribali, K, 2.10.16)

Immigrant Enrollment

  • Undocumented Immigrant Children will get Medi-Cal. “Starting in May 2016, 170,000 undocumented immigrant children in California will have access to Medi-Cal. Governor Jerry Brown signed SB4 into law in October 2015, and it eliminates the immigration status requirement for Medi-Cal eligibility for California residents 18 and under. As long as they qualify based on household income, they’ll be eligible for coverage. For undocumented immigrant adults, SB10 was also introduced in 2015, and will be addressed again once the 2016 legislative session begins in January. SB10 would pick up where SB4 leaves off, allowing adults age 19 and over to enroll in Medi-Cal without regard for immigration status.” (HealthInsurance.com, 10.29.15)

Asset-Rich Enrollees

  • Millionaires Are Qualifying for Medicaid Under Obamacare. “In states that expanded Medicaid, people with high net worths and low monthly incomes qualify for Medicaid because of loosened eligibility requirements implemented under Obamacare. And in rural states like Iowa, Americans whom many would consider wealthy are taking advantage of this loophole and enrolling in coverage paid for by taxpayers. Jesse Patton, an insurance broker living in Iowa, has had clients with net worths ranging from $2 million to $5 million, which often stem from farmland or assets from divorce settlements. And those clients, he said, are enrolled in Medicaid in expansion states like Iowa. ‘It was designed to help the lower-income population,’ Patton told The Daily Signal of Medicaid. ‘But without the asset test, there are folks that have the financial means and assets there that are good at figuring out how to work the system and capture a benefit they’re entitled to.’” (The Daily Signal, 2.9.16)

Enrollment “Churn”

  • Issues In Health Reform: How Changes In Eligibility May Move Millions Back And Forth Between Medicaid And Insurance Exchanges. “Our results show that 35 percent of the adults in our sample would have experienced a change in eligibility within six months, and 50 percent would have experienced a change within one year. Perhaps of even greater concern, 24 percent would have experienced at least two eligibility changes within a year, and 39 percent would have experienced such churning within two years. Beginning in 2014, these income changes may lead to the movement of millions of adults and their families between Medicaid and state exchanges, often within months of their initial enrollment in the programs. Under the Affordable Care Act, income shifts can result in coverage and care disruptions while potentially increasing administrative costs. Furthermore, 43 percent of the adults in our sample had children under age nineteen who, along with their parents, might experience similar disruptions. The magnitude of these effects is quite large: Our 2008 sample corresponds nationally to fifty-six million adults with thirty-five million children… fatigue with frequent coverage changes may lead them to simply stop signing up for insurance over time. This is a problem on two fronts. First, it is uninsured low-income adults who have the most to gain from health reform. Second, this group includes millions of healthy adults whose participation in the exchanges is crucial to robust risk pools. (Health Affairs, February, 2011)

Costs of Medicaid Expansion

Federal Agency Estimates

Coverage Year 2016

  • Congressional Budget Office. The Budget and Economic Outlook: 2017 to 2027 (January, 2017).
    • Spending for Medicaid grew by $19 billion (or 5 percent) last year—about one-third the rate of growth recorded in 2015. The slower growth in 2016 occurred in part because the optional expansion of coverage authorized by the Affordable Care Act (ACA) has been in place for two years and the rapid growth in enrollment that occurred during the initial stage of the expansion has begun to moderate. CBO estimates that total enrollment in Medicaid was 0.4 percent higher in 2016 than in the previous year.
    • Projections, 2017-2027
      • Spending for Medicaid is expected to increase by $20 billion (or 5.5 percent) in 2017. The projected rate of growth in outlays is about the same as last year’s and is well below the average annual rate of growth recorded over the two years before that, primarily because the optional expansion of coverage authorized by the ACA will have been in place for three years and because the rapid growth in enrollment that occurred during the initial stage of the expansion has moderated. CBO projects that, under current law, total enrollment in the program will increase by about 1 percent in 2017, a slightly faster rate of increase than in 2016. Projected outlays for Medicaid, as a percentage of GDP, edge up over the period, from 2.0 percent in 2017 to 2.3 percent in 2027.
      • CBO and JCT currently estimate that federal spending for people made eligible for Medicaid by the ACA will be $70 billion, or 0.4 percent of gross domestic product (GDP), in fiscal year 2017. Such spending is projected to rise at an average annual rate of about 7 percent, reaching $142 billion (or 0.5 percent of GDP) in 2027. For the 2018–2027 period, such spending is projected to total $998 billion if current laws remained in place.

Coverage Year 2015

  • Chief Actuary, Centers for Medicare & Medicaid Services. (August, 2016) 2015 Actuarial Report on the Financial Outlook for Medicaid. 
    • “Medicaid expenditures are estimated to have increased 12.1 percent to $554.3 billion in 2015. Because the Federal government paid for 100 percent of the costs of newly eligible enrollees and the number of these enrollees doubled in 2015, the Federal share of all Medicaid expenditures is estimated to have increased to 63 percent in 2015 (from 61 percent in 2014), and Federal expenditures are estimated to have grown 16.2 percent to $347.5 billion. State Medicaid expenditures are estimated to have increased 5.9 percent to $206.8 billion.
    • Average Medicaid enrollment is estimated to have increased 7.7 percent to 68.9 million people in 2015. Nearly all of the growth in enrollment is estimated to have been among newly eligible adults (4.8 million of the 4.9-million increase).
    • In 2014, the average benefit costs of newly eligible adult enrollees are estimated to have been greater than those for non-newly eligible adult enrollees in the program. Newly eligible adults are estimated to have had average benefit costs of $5,488 in 2014, 12 percent greater than non-newly eligible adults’ average benefit costs, which are estimated to have been $4,914.
    • Per enrollee costs for newly eligible adults are estimated to have grown to $6,366 in 2015 (an increase of 16 percent), while the costs of other adults are estimated to have been $5,159—a difference of 23 percent. These estimates are substantially different from those in last year’s report, in which average benefit costs for newly eligible adults were estimated to decrease by 22 percent from 2014 to 2015.
    • While the newly eligible adult per enrollee costs in 2014 were slightly lower than estimated in last year’s report ($5,488 compared to $5,517, or about 1 percent lower), the estimated per enrollee costs for 2015 in this year’s report are substantially greater ($6,366 compared to $4,281, or about 49 percent higher).”
  • CBO.
    • Under Obamacare, Government Insurance Thrives More than Private Plans. “The cost of Obamacare is expected to rise as millions of low-income people unexpectedly enrolled in public health care coverage rather than private insurance, according to a new government report. These runoff costs, detailed in a report released Thursday, over the next decade are projected to be $146 billion higher than expected for the publicly funded Medicaid program, in spite of the fact that 19 states refuse to participate in the program at this time. The numbers indicate that the federal government fell far short in estimating how many people would enroll in government coverage rather than tax-subsidized but private health insurance. According to the report, Medicaid and Children’s Health Insurance Program enrollees will total 68 million people in 2016 – or 16 million more people than anticipated six years ago, when the law passed. In 2015, Medicaid enrollees increased by 3 million, and by 2026 an additional 6 million are expected to enroll… State lawmakers have said that they are concerned that expansion will be too costly for them, particularly because under the law the federal government gradually dwindles its share of support for the program. A higher-than-expected enrollment in other states could underscore the costs and increase reluctance to expand. In addition, the budget office report shows that half of those who were newly enrolled in Medicaid did so in states that did not expand the program, meaning they may not have known they were eligible before, or were trying to abide by the federal mandate to have insurance.” (US News, 3.25.16)
    • Cost of ObamaCare Subsidies Climbs by 11 Percent. “Much of the $136 billion in extra health spending stems from ‘significantly higher’ enrollment in Medicaid, the federal health program for low-income people, according to the CBO’s latest annual report on healthcare spending… Overall, the cost of healthcare subsidies is expected to grow about 5.4 percent annually as more people enroll in Medicaid.” (The Hill, 3.24.16)
    • CBO: The Budget and Economic Outlook: 2016 to 2026 (January, 2016) “Federal outlays for Medicaid totaled $350 billion in 2015, 16 percent more than spending for the program in 2014. CBO estimates that about two-thirds of that increase resulted from enrollment of people who were newly eligible because of the ACA and from the greater share of costs paid by the federal government for those new enrollees. Under current law, CBO projects, federal spending for Medicaid will jump by almost 9 percent this year as more people in those states that have expanded Medicaid eligibility enroll in the program.”
      • The average monthly enrollment of newly eligible Medicaid beneficiaries was 55 percent higher in 2015 than in the previous year—a total of 9.6 million compared with 6.1 million in 2014. Federal outlays for Medicaid totaled $350 billion in 2015, 16 percent more than spending for the program in 2014. About two-thirds of that increase resulted from enrollment of people who were newly eligible because of the ACA and from the greater share of costs paid by the federal government for those new enrollees.
      • Medicaid spending is expected to increase by $31 billion (or 8.8 percent) in 2016. By 2026, federal outlays for Medicaid are projected to total $642 billion, or about 2.3 percent of GDP (up from 2.1 percent of GDP in 2016).

Coverage Year 2014

  • Center for Medicare and Medicaid Services. (December, 2015) National Health Expenditures 2014. “Total Medicaid spending, which accounted for 16 percent of total national health expenditures, increased 11.0 percent in 2014 after growing 5.9 percent in 2013. State and local Medicaid expenditures only grew 0.9 percent, while federal Medicaid expenditures increased 18.4 percent in 2014. The increased spending by the federal government was largely driven by the newly eligible enrollees under the ACA, which were fully financed by the federal government.”
  • Higher Costs for Obamacare’s New Medicaid Patients. “Last year, the average benefit costs for adults newly eligible for Medicaid were an estimated $5,517 per person, the report by the Office of the Actuary at the Centers for Medicaid and Medicare Services found. That’s 19 percent higher than non-newly eligible adults, whose average benefit costs to Medicaid in 2014 were $4,650. The government previously had estimated that newly eligible Medicaid enrollees would cost 1 percent less on average than already eligible people in 2014, the report noted. The higher-than-expected costs last year were due in large part to pent-up demand for health care among the newly eligible that was greater than states had projected, as well as those new enrollees who were in many cases sicker than had been projected, leading to higher health bills, the report said. About 4.3 million newly eligible adults enrolled in Medicaid in 2014, compared with more than 70 million people overall in the program.” (CNBC, 7.13.15)

Analysis

Items are in reverse chronological order.

  • States Scramble to Head Off Future Medicaid Shortfalls. “States that expanded their Medicaid health insurance programs are hunting for ways to fund the new enrollees in 2020 as they face a final drop in federal contributions. The federal government will still cover the bulk of the costs of care for the roughly 13 million Americans newly eligible for Medicaid under the Affordable Care Act, which allowed states to expand the program to people earning somewhat above the federal poverty level. But the gradually decreasing federal contribution — originally set at 100 percent but reduced to 90 percent starting next year — has left some states with budget holes to fill… the Medicaid program overall consumes the single largest portion of state budgets, accounting for 29 percent of their total spending on average, according to NASBO. States spent $10.3 billion on expansion in the 2018 fiscal year, up from $6.7 billion the year prior.” (Washington Post: The Health 202, 2.21.19)
  • Medicaid Enrollment Declines for the First time in More than a Decade as Strong US Economy Boosts Income for Poor Americans. “Federal and state Medicaid spending still grew despite the drop in enrollment. Combined federal and state spending rose by 4.2 percent in fiscal 2018, similar to the previous year’s increase, Kaiser said. States expect a 5.3 percent jump in spending for 2019.” (CNBC, 10.25.18)
  • Medicaid Expansion Has Appeal, but Significant Costs. “This year, states must absorb 5 percent of expansion costs and could face difficult budget decisions… The federal share of expansion costs gradually declines, dipping to 90 percent by 2020. In contrast, states receive average federal reimbursement of 46 percent for the conventional Medicaid population. While new recipients were originally forecast to cost 30 percent less than those covered before the ACA – the poor, the aged and the disabled – the average per-person cost for the newly eligible was $6,366 in 2015 (49 percent higher than was projected the year prior) and legacy enrollees averaged $5,159. Expansion critics say the higher federal sharing gives state lawmakers an incentive to spend more on those enabled by the ACA. ‘States have set extremely high Medicaid managed-care payment rates for the ACA expansion population,’ claims Brian Blase of the libertarian-leaning Mercatus Center. ‘The real beneficiaries of the ACA Medicaid expansion thus far are health insurance companies and hospitals.’” (National Psychologist, March/April, 2017)
  • New Gruber Study Raises Major Questions About Obamacare’s Medicaid Expansion. “Gruber’s results suggest that people who were already eligible for Medicaid before the ACA have been inappropriately categorized as though they are newly eligible because of the ACA. This is important because the ACA requires the federal government to pay a lot more of the cost of covering newly eligible enrollees than it does for those eligible for Medicaid before the ACA. Thus, it appears the federal government is paying a lot more than it should be and that states are paying far less. Second, Gruber’s results suggest that if the ACA were repealed, a lot fewer people would likely lose coverage than previously thought.” Blase, Brian. (Forbes, 11.27.16)
  • ObamaCare Expansion Enrollment is Shattering Projections: Taxpayers and the Truly Needy Will Pay the Price. (The Foundation for Government Accountability, 11.16.16)
  • States Discover The High Cost Of ObamaCare’s ‘Free’ Medicaid Expansion. “A new report from the conservative Foundation for Government Accountability finds that enrollment in Medicaid expansion states is far higher than projected. It found that the 24 states that made enrollment projections before expanding their programs expected 5.5 million newly eligible people to sign up with Medicaid. The latest data available show that more than 11.5 million did so. ‘Some states have signed up more than four times as many,’ the report notes. In California, for example, UC Berkeley projected that 910,000 more Californians would enroll in Medicaid as a result of the expansion. Turns out that about 3 million did so. Not only are enrollment figures higher than expected, a report from the Centers for Medicare and Medicaid Services found that per-enrollee costs for newly eligible people were 49% higher than expected. And in March, the Congressional Budget Office increased its 10-year cost projection for ObamaCare’s Medicaid expansion by $136 billion. Up until now, these overruns didn’t matter to the states, since the federal government was picking up the bill. But starting January, states have to pony up 5% of the cost for all those newly eligible Medicaid enrollees. (The state share gradually increases to 10%.) As a result, states that expanded Medicaid will see their own Medicaid costs climb almost 6% next year, compared with 4% for states that didn’t expand Medicaid, according to the Kaiser Family Foundation.” (Investor’s Business Daily, 11.18.16)
  • Obamacare Medicaid Enrollees Much More Expensive Than Expected. “The Department of Health and Human Services’ (HHS) annual report on Medicaid’s finances contains a stunning update: the average cost of the Affordable Care Act’s Medicaid expansion enrollees was nearly 50% higher in fiscal year (FY) 2015 than HHS had projected just one year prior. Specifically, HHS found that the ACA’s Medicaid expansion enrollees cost an average of $6,366 in FY 2015—49% higher than the $4,281 amount that the agency projected in last year’s report… The rates are much higher than the amounts for previously eligible Medicaid adult enrollees and suggest that states are inappropriately funneling federal taxpayer money to insurers, hospitals, and other health care interests through the ACA Medicaid expansion.” Blase, Brian. (Forbes, 7.20.16)
  • President Obama Double Downs On Medicaid’s Failures. “President Obama almost never mentioned the word ‘Medicaid’ when pitching his health reform package in 2009. When he did, it was always to say that Medicaid was ballooning the federal deficit. Without Obamacare, he warned, Medicaid would ‘blow a hole through our budget.’ Well, the president got his reform. Yet Medicaid is still blowing a hole through the federal budget. Last year, Medicaid spending shot up 14% — topping a spike of 10% in 2014. The CBO expects Medicaid costs to go up another 7% this year. This year, Obamacare will add $74 billion to Medicaid’s tab — $12 billion more than the CBO projected just two years ago. Medicaid’s costs are higher than expected because the program has enrolled more people than congressional bean-counters envisioned.” Pipes, Sally. (Forbes, 4.18.16)
  • Opposing Medicaid Expansion. “States are faced with tough fiscal choices each year as they strive to balance their budgets. Medicaid already takes up the largest share of most state budgets, and its costs grow much faster than revenue. ‘Everything has taken a backseat to the Medicaid budget,’ says Maine Rep. Deborah Sanderson, Republican ranking minority member of the state’s health and human services committee. ‘We feel it every session.’ Maine Gov. Paul LePage, a Republican, has vetoed Medicaid expansion three times during the 126th legislature, and it remains the only state in the Northeastern part of the U.S. that hasn’t taken part. Over the years states have sacrificed other portions of the budget, including transportation and infrastructure, to pay for Medicaid. It doesn’t help that health care is growing faster than the rest of the economy, nor that the cost of prescription drugs has heaped demands on the program. Further, government analysts say Medicaid is one of the main causes for the growth in the rate of health care spending… Some lawmakers have said they don’t trust that the federal government will honor its commitment to keep up this level of support over the long term, and others say that even paying 10 percent of the cost is too much for their already-strained budgets. ‘Ten percent of $5 billion is a lot of money,’ says Sanderson.” (US News, 12.4.15)

Cost by State

Arkansas

  • “By January 2015, Medicaid expansion enrollment had reached 233,518.  During just the first six months of expansion, Arkansas ran $137 million over budget, meaning the ObamaCare expansion cost taxpayers 61 percent more than the state’s actuaries projected and the welfare expansion’s supporters promised.” (Foundation for Government Accountability, 4.20.15)

California

  • Obamacare’s Best is not Good Enough. “Contrary to expectations, a large portion of California’s newly-insured under Obamacare were enrollees in the state’s Medicaid program, Medi-Cal. Official projections for Medi-Cal enrollment prior to the state’s expansion of Medicaid were about 1.5 million over of the first year. Yet more than 4 million residents signed up for the program during that time. As a result of this rapid expansion, one out of every three Californians is now enrolled in a program originally designed only for California’s poorest and most vulnerable residents, and the entitlement is crowding out other state budget priorities.” (Forbes, 6.22.16)
  • Under Obamacare, Medi-Cal Ballooned to Cover 1 in 3 Californians. “The state’s health plan for the poor, known as Medi-Cal, now covers 12.7 million people, 1 of every 3 Californians. If Medi-Cal were a state of its own, it would be the nation’s seventh-biggest by population; its $91-billion budget would be the country’s fourth-largest, trailing only those of California, New York and Texas… ‘Obviously with that comes cost.’ The question California officials now face is how — and on days with a gloomier economic outlook, if — the massive health program can be sustained.” (Los Angeles Times, 12.31.15)
  • Thousands Mistakenly Enrolled During California’s Medicaid Expansion, Feds Find. “California signed up an estimated 450,000 people under Medicaid expansion who may not have been eligible for coverage, according to a report by the U.S. Health and Human Services’ chief watchdog. In a Feb. 21 report, the HHS’ inspector general estimated that California spent $738.2 million on 366,078 expansion beneficiaries who were ineligible. It spent an additional $416.5 million for 79,055 expansion enrollees who were “potentially” ineligible, auditors found. Auditors said nearly 90 percent of the $1.15 billion in questionable payments involved federal money, while the rest came from the state’s Medicaid program, known as Medi-Cal.” (Kaiser Health News, 3.28.18)

Illinois

  • “By the end of the year, more than 540,000 adults signed up for ObamaCare expansion, far more than the state thought would ever even be eligible. As a result, Illinois’ Medicaid expansion ran $800 million over budget in the first year alone.” (Foundation for Government Accountability, 4.20.15)
  • President Obama Double Downs On Medicaid’s Failures. “In Illinois, the state’s projected costs between 2017 and 2020 have increased from $573 million to $2 billion. Pipes, Sally. (Forbes, 4.18.16)

Iowa

  • Iowa Scraps Waiver for Obamacare Medicaid Expansion. “When policymakers were debating Medicaid expansion, state officials predicted the program would cost between $71 million and $115 million in fiscal year 2014. But according to data recently provided by the Iowa Department of Human Services, actual expansion costs totaled more than $258 million. If that weren’t bad enough, state and federal officials are already bracing for higher costs. Earlier this year, the Obama administration increased the budget cap in Iowa’s Medicaid expansion waiver. The new cap is nearly 5 percent higher per-person than in the original agreement.” (Forbes, 9.14.15)

Kentucky

  • “By the end of the first year, more than 375,000 able-bodied adults enrolled into ObamaCare expansion, roughly double the number the state thought would ever sign up. As a result, Kentucky budget officials now estimate Medicaid expansion will cost $1.8 billion more than projected in fiscal years 2014 and 2015.”  (Foundation for Government Accountability, 4.20.15)
  • “Senate President Robert Stivers (R) estimates it will cost Kentucky $250 million over the next two years to fund the Medicaid expansion plan. In January, Kentucky lawmakers will vote on a two-year spending plan that must include this amount.” (Becker’s Hospital Review, 12.3.15)
  • Kentucky could be looking at annual costs of $363 million by 2021. Pipes, Sally. (Forbes, 4.18.16)

Louisiana

  • Finding Woodworkers in Louisiana. “Louisiana is expanding Medicaid with the new eligibility date starting on July 1st.  The Times Picayune  reports that Louisiana is using its SNAP (food stamp) database as a means of identifying individuals who are Expansion eligible and then automatically signing them up… The most interesting angle to me is how does this outreach change the Medicaid cost savings for Louisiana. The woodworkers have a FY2017 62/38 Federal/state split on their costs. The Expansion eligible individuals have a CY2016 100/0 split on their costs. A large rush of legacy woodworkers will eat up most of the cost savings gained through lower charity care appropriations, and shifting of voluntary Legacy Medicaid qualified individuals to Expansion eligibility groups… However the problem is Louisiana has a balanced budget constraint and a large structural deficit… a 100% Medicaid Eligibility uptake rate would take away most of the savings.” (Balloon Juice, 5.9.16)

Massachusetts

  • In a Setback for Massachusetts, Healthcare Costs Spike in State. “The soaring costs of insuring the state’s poorest residents drove health care spending in Massachusetts up 4.8 percent last year, double the rate of growth in 2013, dealing a setback to the state’s efforts to contain medical costs. The increase far exceeds inflation, which was 1.6 percent last year, and blows past a state goal of holding health care spending growth to 3.6 percent annually, according to a report to be issued Wednesday by the state Center for Health Information and Analysis…The new state report shows that last year’s spending increase was concentrated in the state’s Medicaid program, known as MassHealth, where spending surged 19 percent after rising less than 5 percent in 2013. MassHealth, funded by taxpayers, provides insurance to 1.8 million low-income residents.” (Boston Globe, 9.2.15)
  • Does Romneycare Offer any Lessons for Utah’s Obamacare Medicaid Expansion Debate? “Unfortunately most trends in Massachusetts have been moving in the wrong direction since expanding Medicaid. First, after initially seeing a decline in the amount of uncompensated care for the uninsured, demand in Massachusetts has spiked back to over $600 million to $700 million a year, and the number of patient visits being paid for under this Health Safety Net fund has actually gone up…Since the Obamacare expansion, the cost of the Commonwealth’s Medicaid program has exploded, with costs increasing by $2.9 billion last year alone. With one in four Massachusetts residents now on Medicaid, the price tag is a whopping $16 billion a year, nearly half the state’s annual budget.” (Deseret News, 9.25.15)

New Jersey

  • Why Did Chris Christie Embrace Obamacare’s Expansion Of Medicaid? “Christie argued that New Jersey taxpayers would save $227 million in 2014, because the federal government’s infusion of Medicaid dollars would pay for uncompensated care for the uninsured, and because some of New Jersey’s spending on Medicaid will be replaced by federal spending on Medicaid… Through 2022, the Heritage Foundation estimates that Christie’s Medicaid expansion will cost New Jersey taxpayers about $1.2 billion. Those estimates precede news that the New Jersey Medicaid rolls have increased by over 400,000 since Christie’s decision. That’s 71 percent more than the 233,000 that the expansion was projected to cover in 2012. In April, the Wall Street Journal reported that the state had been “overwhelmed” by the surge in enrollment.” Roy, Avik. (Forbes, 12.27.15)

New Mexico

  • ObamaCare Costs Coming Home to Roost for New Mexico. “According to a front page story in the Albuquerque Journal which related testimony from the Legislative Finance Committee, Medicaid is going to bankrupt New Mexico in the near future. Rep. Jason Harper said… ‘Medicaid is going to be a budget-buster,’ and Rep. Larranaga described Medicaid as a ‘runaway train.’ Just to be clear, New Mexico is looking at a one year Medicaid spending increase from $891.7 million to $976.9 million. That’s a 8.5 percent one-year hike. With the federal government’s share of Medicaid expansion costs declining from 100% to 95% in 2017, there is no doubt that New Mexico faces real and long-term budgetary challenges.” (Errors of Enchantment, 10.28.15)
  • Medicaid: More of the Same. “The state’s healthcare program for ‘the poor,’ expanded by Governor Martinez under Obamacare, is spewing a river of red ink. Medicaid is projected to generate a deficit of $417 million in the 2016 and 2017 fiscal years. And the future is likely to be even darker. By 2020, the state estimates that 43 percent of New Mexicans will be signed up for ‘free’ healthcare. To cut costs, the Human Services Department is proposing to ‘rescind previous reimbursement increases to nearly 2,000 general physicians and trim payment rates to hospitals by between 3 percent and 8 percent.’” (Errors of Enchantment, 4.27.16)

New York

  • Medicaid Care Plan Pulling Out of 3 Counties Because of ‘Calamitous’ Reimbursement. “New York State’s largest Medicaid managed long-term care plan will no longer enroll members in Nassau, Suffolk and Westchester counties, according to a letter its chief sent to the state Department of Health. Alan Morse, CEO of GuildNet, told the Cuomo administration the ‘calamitous state of reimbursement’ made it no longer feasible to operate because the program was incurring ‘substantial deficits.’… One year ago, EmblemHealth also pulled out of the managed long-term care program. At the time, those patients went to GuildNet. Now, they will have to find another plan.” (Politico, 11.23.16)

Ohio

  • Ohio Obamacare Expansion Costs $3 Billion in First 15 Months. “After Kasich expanded Medicaid unilaterally, a state panel approved $2.56 billion in Obamacare spending for the expansion’s first 18 months. The money was meant to last until July, but it ran out in February. Kasich’s Obamacare expansion cost $323 million in March — 84 percent greater than estimates revised just six months earlier…Kasich’s Obamacare expansion is on track to cost more than $4 billion by the end of June. With federal taxpayers on the hook for all benefit costs and Ohio facing a growing state share in 2017, Obamacare expansion may soon consume 10 percent of Ohio’s budget. (Ohio Watchdog, 4.29.15)
  • “Kasich’s Medicaid expansion has cost federal taxpayers more than $5 billion in less than two years, and the state will be on the hook for part of the costs starting in 2017. The governor backed Republican legislative supermajorities in the Ohio House and Ohio Senate into a corner on Medicaid, convincing most to sign off on a continuation of Obamacare’s welfare coverage for working-age adults with no kids and no disabilities.” (Watchdog.org, 12.28.15)
  • Tab for John Kasich’s Obamacare Expansion Tops $6 Billion. “Since January 2014, Kasich’s expansion of Medicaid to working-age adults with no kids and no disabilities has added 5% of Ohio’s population to the welfare rolls and has cost federal taxpayers $6.4 billion.” (Hot Air, 1.21.16)
  • Kasich’s Medicaid Expansion Has Cost Taxpayers $7 Billion. “Kasich’s Obamacare expansion cost an average of $391 million per month — more than $1.5 billion per quarter — during the past six months. At this rate, expansion will cost $14.1 billion by August 2017 and $27.5 billion by June 2020. Revised cost projections for the 2016-17 state budget were optimistically low, too. With four months left in the 2016 fiscal year, Obamacare expansion has cost $2.5 billion — 9 percent more than lawmakers estimated last spring. Propelled by Obamacare expansion, Ohio’s Medicaid program cost $1 billion more through February than at the same point in 2015, a 6.6 percent increase.” (Watchdog.org, 3.21.16)

Oregon

  • Oregon Lawmakers Consider Ending Medicaid Expansion to Shore Up Budget. “Democratic lawmakers in Oregon are considering ending the state’s Medicaid expansion in an effort to address a $1.6 billion budget shortfall. The state’s Ways and Means committee, which includes both senators and representatives, suggested cutting Medicaid expansion in an effort to curb Oregon’s $1.6 billion budget deficit. ‘We are simply laying out possibilities for how the state may deal with the stark realities of a projected $1.6 billion deficit,’ Rep. Nancy Nathanson, co-chair of the Ways and Means committee said in an email. Ending Medicaid expansion, which has led to 350,000 people gaining coverage, would save the state $256 million over the next two years.” (Modern Healthcare, 4.19.17)
  • Oregon’s High-Risk, High-Reward Gamble On Medicaid Expansion. “Even though it met its cost growth objectives for the waiver, the costs for the ambitious coverage expansion to Oregon taxpayers are mounting rapidly. For the two-year budget 2017-2018, Oregon faces a $700 million deficit due to Medicaid, created by two changes in federal matching formulae: the resetting of the federal match for the 400,000 newly eligible from 100 percent to 95 percent, and a downward readjustment of the match for the rest of its Medicaid population based on improvements in Oregon’s per capita income.” (Health Affairs, 1.10.17)

Pennsylvania

  • Medicaid Expansion and Pennsylvania. (April, 2014) (pdf). Pennsylvania Department of Public Welfare. “Initial estimates show that expanding Medicaid, as proposed in the ACA, would cost Pennsylvania almost $1 billion of new state taxpayer dollars through FY 2015-2016; rising to a total of over $4.1 billion of new state taxpayer dollars by the end of FY 2020-2021. Pennsylvania is striving to maintain a health safety net for its citizens, while maintaining fiscal stability for our taxpayers. However, with continued large annual cost increases of the current Medicaid program, serious questions exist as to the sustainability of an expansion of Medicaid without significant reform of the program.”

Utah (expansion proposed)

  • Obamacare’s Unlikely Supporters: Utah Cops. “Police chiefs and sheriffs who run local jails in states that haven’t expanded Medicaid are coming out in favor of Obamacare on the grounds that it could help drug addicts and people with mental illness get help before they commit crimes… Jim Winder, the elected sheriff of Salt Lake County, says 15 percent to 18 percent of the 40,000 people booked each year into the county jail—Utah’s largest—are severely mentally ill, about the same as the national rate. He spends $3 million to $5 million a year on psychotropic medication, out of a budget just shy of $90 million. Even if inmates have private insurance, the jail picks up the tab for them while they’re locked up.” (Bloomberg, 6.5.15)

Vermont

  • Shumlin Wants Physicians and Dentists to Pay Medicaid Expansion Costs. “That lack of courage was a reference to the Legislature’s refusal to fund Medicaid with a 0.7 percent payroll tax, as Shumlin requested in last year’s budget address. Without that revenue and matching federal funds, Shumlin said, Medicaid expansion has run up a deficit of $55 million — roughly three-fourths of the $68 million hole… the governor wants the Legislature to make independent physicians and dentists pay the same provider assessment that hospitals and nursing homes pay, but at half the rate. Doing so would raise $17 million in new revenue and draw down federal funds of $21 million — a total of $38 million for Medicaid.” (Watchdog.org, 1.21.16)

Virginia

  • Virginia Facing High Unexpected Medicaid Costs. “State officials said Friday that Virginia has about $460 million in unforeseen Medicaid costs…. Secretary of Finance Aubrey Layne said much of the new costs stem from faulty forecasts overestimating the benefits of having private health insurers cover a greater number of some of the state’s more costly Medicaid recipients. Another reason for the increase is a higher-than-expected enrollment of children in the state’s Medicaid program, he said.” (Associated Press, 11.2.18)

Wisconsin (expansion proposed)

  • Erpenbach Makes Wisconsin Taxpayers Sick. “In an opinion requested by state Sen. Jon Erpenbach, the Legislative Fiscal Bureau (LFB) has the latest numbers for a proposed expansion of Medicaid under Obamacare. Despite what Erpenbach and his fellow Democrats claim, the latest estimate confirms that Wisconsin made the correct decision to reject the additional federal funding… By 2021, instead of ‘saving’ $1.07 billion, spending would increase $3.14 billion at the federal level for a net increase in government spending of $2.07 billion. Meanwhile Wisconsinites would be directly on the hook in perpetuity for at least 10 percent of the increased cost of Medicaid in Wisconsin. Given the uncertainty surrounding Obamacare’s long-term viability, the percentage Wisconsin would pay could actually climb. As Speaker of the House Paul Ryan said in an interview in 2013, ‘The fastest thing that’s going to go when we’re cutting spending in Washington is a 100 or 90 percent match rate for Medicaid. There’s no way. It doesn’t matter if Republicans are running Congress or Democrats are running Congress. There’s no way we’re going to keep those match rates like that.’” (MacIver Institute, 12.17.15)

Medicaid Expansion Pros and Cons

The Case for Medicaid Expansion

The Case Against Medicaid Expansion

  • Conover, C.J. Should States Expand Medicaid?  The Apothecary (Forbes.com), February 6 2013. The author offers three reasons states might legitimately be hesitant to expand Medicaid:
    • Families with incomes between 100-138% of poverty would be better off without expansion as they would be eligible for fully subsidized coverage under the Obamacare exchanges.
    • States that have expanded Medicaid may face enormous unexpected fiscal liabilities were comprehensive immigration reform ever enacted.
    • States likewise might face higher-than-anticipated fiscal burdens stemming from the “woodwork” effect as previously eligible-but-not-enrolled recipients sign up for coverage.
  • Conover, C.J. States Face a Sophie’s Choice on Medicaid Expansion  The Apothecary (Forbes.com), February 7, 2013. The author notes that Medicaid expansion would benefit below-poverty beneficiaries at the expense of worse health outcomes (including higher mortality risk) for near-poor recipients between 100-138% of poverty.
  • Conover, C.J. The Case Against Medicaid Expansion in North Carolina. NC Medical Journal 78(1): 48-50. Authors offers 5 arguments against expansion:
    • Expansion will reduce access for existing Medicaid recipients.
    • Expansion is unlikely to save lives.
    • Expansion is unaffordable in the long run (the 90% federal matching rate is not likely to persist in perpetuity).
    • Medicaid financing encourages fiscal irresponsibility.
    • Expansion will eliminate more jobs than it creates.
  • Conover, C.J. Will Medicaid Expansion Create Jobs?  The Apothecary (Forbes.com), February 25, 2013.
  • Conover, C.J. Fixing the Three Biggest Flaws in Obamacare’s Medicaid Expansion, Part 1. The Apothecary (Forbes.com), June 14, 2017. The author argues that the 90% enhanced Medicaid rate is flawed for three reasons:
    • States vary greatly in their altruistic willingness-to-pay, so a “one-size-fits-all” federal standard is inappropriate.
    • ACA privileges able-bodied adults over historically-favored vulnerable populations. There is no moral justification for this undemocratic “end-around” of inconvenient public preferences that favor pregnant women, infants, children and the disabled over able-bodied adults.
    • Enhance matching puts on steroids the already-problematic perverse incentives to waste money in the Medicaid program.
  • Conover, C.J. Fixing the Three Biggest Flaws in Obamacare’s Medicaid Expansion, Part 2. The Apothecary (Forbes.com), June 16, 2017. The author argues that Obamacare did nothing to correct the flawed open-ended matching rate structure that creates perverse incentives for states to waste money:
    • Medicaid’s open-ended matching rate encourages fiscal irresponsibility.
    • Consequently, Medicaid is now crowding out education and other critical state priorities.
    • Medicaid has become a boon-doggle for wealthy states and Obamacare tilted the playing field even further in their direction.
  • Conover, C.J. Fixing the Three Biggest Flaws in Obamacare’s Medicaid Expansion, Part 3. The Apothecary (Forbes.com), June 20, 2017. The author argues that lack of integration with private coverage under the Medicaid expansion has created three avoidable problems:
    • Medicaid “crowd-out” of private coverage is 60% under the expansion.
    • Nearly 7 million Medicaid recipients annually will experience “churn” in their coverage as they bounce between Medicaid and private coverage.
    • Medicaid eligibility creates perverse work incentives.
  • Who is on the ObamaCare Chopping Block? The Immoral Funding Formula of ObamaCare’s Medicaid Expansion Puts the Neediest Patients at Risk. Foundation for Government Accountability (7.17.14). “ObamaCare’s new Medicaid entitlement for working-age, able-bodied adults ultimately redirects limited state and federal resources away from truly needy patients. These vulnerable individuals already struggle in a tattered Medicaid safety net. Care is frequently fragmented, access to quality care is often low and health outcomes remain poor. Rather than fixing Medicaid for the truly needy, ObamaCare’s Medicaid expansion overloads the safety net with able-bodied adults and prioritizes them over the nation’s most vulnerable patients.”

Research and Analysis

Impact on Access to Care

Evidence of a Positive Impact on Access to Care

  • Department of Family Medicine, Oregon Health and Science University, (2018). The Impact of the Affordable Care Act (ACA) Medicaid Expansion on Visit Rates for Diabetes in Safety Net Health Centers. “Contrary to our hypothesis, total visit rates for the population of patients with diabetes pre-ACA versus post-ACA were stable, which is likely due to the accessibility of care provided by CHCs. In addition to accessible care, CHCs provide high-quality care; they exceed Healthy People 2020 goals in various health outcomes, including diabetes control.[18] These findings reinforce the importance of CHCs for delivering care to vulnerable populations with chronic disease. Notably, even though the total number of visits for the population of patients with diabetes did not change, diabetes-specific screening rates increased, suggesting that insurance coverage had a positive impact on the receipt of timely preventive care.”

Evidence of a Negative Impact on Access to Care

  • A Republican Governor is Fighting for Obamacare. “Obamacare gives states far more federal money for their Medicaid expansion enrollees than for those covered by traditional Medicaid, creating a perverse incentive for state lawmakers to prioritize childless, able-bodied adults over pregnant women, the elderly, children, and disabled individuals on Medicaid waiting lists… With enrollment far higher than anticipated and per-enrollee costs 49 percent higher than projected last year, Obamacare expansion’s burden on federal taxpayers and the truly needy will keep getting worse unless Congress ignores Gov. Kasich and follows through on promises to repeal Obamacare.” (Hot Air, 1.13.17)

Impact on Health Outcomes

Evidence of a Positive Impact on Health Outcomes

  • Council of Economic Advisors. Missed Opportunities: The Consequences of State Decisions Not to Expand Medicaid.  July 2014. This report summarizes the benefits of Medicaid expansion, including direct benefits to the newly uninsured (improved access to care, greater financial security, better mental health and better overall health) as well as benefits to state economies (additional federal funds, more jobs, greater overall economic activity). The report includes quantitative estimates of each of these impacts.

Evidence of a Neutral Impact on Health Outcomes

  • Conover, C.J. Reality Check: The Obamacare Medicaid Expansion is Not Saving Lives, Part 1. The Apothecary (Forbes.com), June 30, 2017.
  • Conover, C.J. Reality Check: The Obamacare Medicaid Expansion is Not Saving Lives, Part 2. The Apothecary (Forbes.com), June 30, 2017.
  • Wadhera, Rishi K. et al. (2018). Fewer Uninsured but Similar MI Outcomes With Medicaid Expansion. “‘Medicaid expansion did what it was supposed to: it significantly reduced the rate of uninsurance among that group, which presumably protected these people from significant financial harm from this acute event,’ said cardiologist and health policy researcher Karen Joynt Maddox, MD, MPH, Washington University, St. Louis, Missouri. ‘But what we did not see was any change in quality of care or mortality in low-income populations in expansion versus nonexpansion states,’ she said. Patients in expansion states were more likely to receive defect-free AMI care in the postexpansion period, although the increase was small (P = .01). However, the increase in defect-free care in the postexpansion period was actually greater in the nonexpansion states (P < .001; P < .001 for interaction).”
  • Revisiting the Connection Between State Medicaid Expansions and Adult Mortality. “We evaluate the long-run effects of eight state Medicaid expansions from 1994 through 2005 on all-cause, healthcare-amenable, non-healthcare-amenable, and HIV-related mortality rates using state-level data. We utilize the synthetic control method to estimate effects for each treated state separately and the generalized synthetic control method to estimate average effects across all treated states. Using a 5% significance level, we find no evidence that Medicaid expansions affect any of the outcomes in any of the treated states or all of them combined. Moreover, there is no clear pattern in the signs of the estimated treatment effects. These findings imply that evidence that pre-ACA Medicaid expansions to adults saved lives is not as clear as previously suggested.” (Courtemanche et al,, January 2023).

Evidence of a Negative Impact on Health Outcomes

  • Thanks To Obamacare, People Are Dying On Wait Lists For Care. “Because states get a higher federal match for expanding Medicaid to able-bodied adults than covering home-care needs for individuals with disabilities, more than half a million disabled Americans wait—and wait, and wait some more—to get access to needed care. Except for those who die before they can access care. Last month, reports from Illinois noted that no fewer than 752 individuals with disabilities have died—yes, died—while on waiting lists to receive Medicaid services since that state expanded coverage under Obamacare… As I have previously noted, this dynamic hasn’t just happened in Illinois. It has occurred all over the country. In Arkansas, Gov. Asa Hutchison pledged to cut waiting lists for individuals with disabilities in half. Instead, they have grown by 25 percent, even as the state expanded coverage to the able-bodied. In Ohio, Gov. John Kasich cut Medicaid eligibility for individuals with disabilities by 34,000, even as he unilaterally expanded the program to other Ohioans.” Jacobs, Chris. (The Federalist, 12.16.16)
  • Hundreds on Medicaid Waiting List in Illinois Die While Awaiting Care. “The Illinois General Assembly opted to expand Medicaid through Obamacare in May 2013. This expansion created a new Medicaid category for able-bodied adults ages 19-64 with incomes below 138 percent of the federal poverty level. But the Medicaid program was designed to serve the truly vulnerable – the aged, the blind and the disabled – and expansion critics have long warned that creating a new welfare class would prioritize able-bodied adults and put more vulnerable people at risk by redirecting limited resources. Now, newly obtained data from the Illinois Department of Human Services, or DHS, confirm these fears. According to documents provided by the department, 752 Illinoisans on the state’s Medicaid waiting list have died awaiting needed care since the General Assembly voted to accept the Obamacare expansion for able-bodied adults. That’s 18 deaths each month, on average, since the expansion was authorized.” (Illinois Policy, 11.23.16)

National Studies

  • ASPE. Understanding Participation Rates in Medicaid: Implications for the Affordable Care Act (March 2012). There is a great deal of uncertainty about the impact of Medicaid expansion due to wide variations in assumed take-up rates used in various models. This issue brief reviews the empirical evidence regarding take-up rates and summarizes the various projections and their underlying take-up assumptions.  Among 8 different projections, the assumed take-up rates range from 57% to 95% producing projected Medicaid enrollment ranging from 13.4 to 25.9 million.
  • Buchmueller, Thomas, John C. Ham, and Lara D. Shore-Sheppard. The Medicaid Program (NBER Working Paper No. 21425, July 2015).
  • Cato Institute. Medicare and Medicaid.
  • Commonwealth Fund (December 2013). Sherry Glied and Stephanie Ma. How States Stand to Gain or Lose Federal Funds by Opting In or Out of the Medicaid Expansion. Commonwealth Fund pub. 1718, December 2013.
  • FamiliesUSA. Mahan, Dee. Medicaid Expansion’s Possible Effects on Health Sector Employment Growth (Families USA, Aug. 2014).
  • Foundation for Government Accountability. Congressional Research Service: There’s No Magic Pot Of Obamacare Medicaid Expansion Money. (3.12.15) “A recent report from the Congressional Research Service (CRS) confirms what many policy experts have known for some time: states that reject Obamacare’s Medicaid expansion aren’t sending that Medicaid expansion money to other states. Instead, that money is simply never spent. This revelation is important because numerous governors and state lawmakers from across the country have used this argument to justify their support for expanding Medicaid through Obamacare. However, as CRS succinctly explains, these arguments are entirely frivolous.”
  • Gross, T. and Notowidigdo, M. (2011). Health Insurance and the Consumer Bankruptcy Decision: Evidence from Expansions of Medicaid. Journal of Public Economics 95(7-8): p. 767-778. “Using cross-state variation in Medicaid expansions from 1992 through 2004, we find that a 10 percentage point increase in Medicaid eligibility reduces the personal bankruptcy rate by 8.4 percent, with no evidence that business bankruptcies are similarly affected.”
  • Hall, J., et al. (2018). Medicaid Expansion as an Employment Incentive Program for People With Disabilities. Am J Public Health. 2018;108(9):1235-1237. “In Medicaid non-expansion states, most adults with disabilities must continue to apply for Supplemental Security Income (SSI) and undergo a disability determination process affirming that they cannot substantially work to be eligible for Medicaid. It was not surprising then that we found no significant change in the share of adults reporting not working because of a disability (P= .42) in nonexpansion states, where a disability determination is still necessary for Medicaid eligibility. In Medicaid expansion states, however, a significant change over time was found: people with disabilities were significantly less likely to report not working because of a disability post-ACA compared with pre-ACA (P = .036). This finding indicates that in Medicaid expansion states, the need for adults with disabilities to prove an inability to work to obtain Medicaid coverage is decreasing… The increase in the share of people reporting that they were employed was greater in expansion than in non-expansion states.”
  • Heritage Foundation. Medicaid.
  • Kaiser Family Foundation.
  • New England Journal of Medicine. Medicare and Medicaid.
  • Robert Wood Johnson Foundation, State Coverage Initiatives. The ACA and Recent Section 1115 Medicaid Demonstration Waivers (February 2014). Prior to the ACA, one key reason a number of states used Section 1115 waiver authority was to expand Medicaid coverage to low-income adults who could not otherwise be covered under federal rules. The ACA’s Medicaid expansion to nearly all low-income adults at or below 138% FPL, and the significant federal funding provided to states for this expansion, fundamentally alters the role of Section 1115 waivers in expanding coverage to adults. Through guidance and recent waiver approvals in three states, CMS has identified some of the parameters related to the use of waivers to expand coverage to adults in light of the ACA’s Medicaid expansion. This brief provides an overview of the potential role of Section 1115 waivers to expand coverage since the enactment of the ACA and key themes in recently approved and proposed coverage expansion waivers.
  • Robert Wood Johnson Foundation, State Health Reform Assistance Network
  • Roehrig, Charles, Ani Turner, and Katherine Hempstead. Expanded Coverage Appears To Explain Much Of The Recent Increase In Health Job Growth. Health Affairs Blog (Nov. 20, 2015).
  • Sommers B. and Oellerich D. (2012) The Poverty-reducing Effect of Medicaid. Journal of Health Economics. We find that Medicaid reduces out-of-pocket medical spending from $871 to $376 per beneficiary, and decreases poverty rates by 1.0% among children, 2.2% among disabled adults, and 0.7% among elderly individuals. When factoring in institutionalized populations, an additional 500,000 people were kept out of poverty. Overall, Medicaid kept at least 2.6 million—and as many as 3.4 million—out of poverty in 2010, making it the U.S.’s third largest anti-poverty program.
  • University of Michigan. (5.15.18) Medicaid Expansion Leaves More Money in Recipients’ Pockets.  “Joelle Abramowitz, an economist with the U-M Institute for Social Research, examined the extent to which the expansion alleviated the burden of out-of-pocket costs of getting health insurance and then using it. These include costs such as monthly premiums, doctor’s visit copays and copays for medication, medical supplies and vision aids such as glasses or contacts. The study found that those living in states that expanded Medicaid were less likely to pay premiums for their Medicare insurance. These residents also saw their out-of-pocket medical expenses such as copays decrease. ‘I studied people who were near or below the poverty level, who could do a lot with that money,’ said Abramowitz, an assistant research scientist with ISR’s Survey Research Center. ‘On the other hand, if this leads people to seek care they wouldn’t have sought before, they may end up spending more.’ The findings also pointed to another outcome: Medicaid expansions also led to workers dropping their employer-sponsored health insurance. Abramowitz surmises that this is because Medicaid coverage may be better and less costly.”
  • Urban Institute.
  • Washington Examiner. Medicaid Eligibility and Obamacare. December 12, 2014. “There are states in which individuals living in poverty without children would not be eligible for Medicaid benefits. For a full breakdown of the eligibility standards of different categories of people in different states, check out this table.”
  • National Association of State Budget Officers. U.S. States Get More, Spend More on Medicaid Under Obamacare. (Reuters, 11.20.14). “One part of the Affordable Care Act is going according to plan, with U.S. states receiving and spending more money on the Medicaid health insurance program, a report released by the National Association of State Budget Officers on Thursday showed.… ‘Looking forward, states remain concerned about both the short- and long-term outlook due to increased spending demands, recent volatility in states revenues, and uncertainty surrounding future federal fiscal policies,’ NASBO found.”
  • New York Times (11.8.18). When Medicaid Expands, More People Vote. “Obamacare didn’t just give more people health insurance. It also caused more people to vote. That’s the conclusion of a new body of evidence that strongly suggests that giving people coverage through expansions of the Medicaid program increases their likelihood of participating in the next election. Medicaid expansions seem to raise both voter registration and voter participation, at least temporarily… the people eligible for Medicaid expansion tend to be poor, single adults, a demographic more likely to be Democratic-leaning. And the Oregon study showed bigger voting effects in more heavily Democratic parts of the state.”

State-Level Medicaid Expansion Economic Impact Studies

Public Opinion

  • In a December 2014 Kaiser Family Foundation poll, 52% of Republicans said they had a favorable view of Medicaid expansion, 44% had an unfavorable view, and 3% did not voice an opinion.
  • In the same poll, as the chart above shows, 56% of Republicans in states that had not expanded Medicaid had a very favorable (23%) or somewhat favorable (33%) view of expansion.

State Experience

Participation by State

As of January 4, 2019, Kaiser Family Foundation reported that 37 states including DC had adopted the Medicaid expansion allowed by the ACA. 14 States were Not Moving Forward at this Time (AL, FL, GA, KS, ME, MO, MS, NC, OK, SC, TN, TX, UT, WI). Note below that the NH waiver expires 12.31.16 unless it is renewed by the state legislature. On 12.27.15, New York Times reported that in Tennessee and Utah, Republican governors are pressing for wider Medicaid coverage despite opposition from state legislatures, while Alabama’s governor is reconsidering expansion after previously rejecting it.
Coverage under the Medicaid expansion became effective January 1, 2014 in all states that have adopted the Medicaid expansion except for the following: Michigan (4/1/2014), New Hampshire (8/15/2014), Pennsylvania (1/1/2015), Indiana (2/1/2015), Alaska (9/1/2015), Montana (1/1/2016), and Louisiana (7/1/16), Virginia (1/1/2019), and Idaho, Maine, Nebraska, and Utah (to be determined). Per Centers for Medicare and Medicaid Services (CMS) guidance, there is no deadline for states to implement the Medicaid expansion.

  • Alabama. “In perhaps his most direct comments to date, Gov. Robert Bentley said Thursday his administration is looking at expanding Medicaid, the health care program that serves one million Alabamians. “We are looking at that (Medicaid expansion). We have not made a final decision on that yet, exactly on how that will work,” said Bentley in response to a question from an audience of lawyers he addressed this morning in Montgomery.  “If we were to accept that (Medicaid expansion and federal dollars) you have to realize it is going to cost the state of Alabama over the next six years $710 million in the General Fund,” said Bentley who noted that he had just finished a bruising battle with the Legislature over raising taxes to better help fund the beleaguered General Fund.” (AL.com, 11.12.15)
  • Alaska. According to Josh Archambault (8.25.15), Alaska Governor Bill Walker (I) announced in mid-July that he was moving forward with plans to unilaterally expand Medicaid in the state. “As we’ve previously written here at Forbes, Walker’s expansion plan is not only bad policy, it’s also likely illegal. Now, a courageous group of Alaska lawmakers – led by Senate President Kevin Meyer and House Speaker Mike Chenault –  are standing up to Gov. Walker’s attempted end-run around the legislature and hiring an all-star legal team to block Walker’s illegal actions.”
  • Arkansas. According to NY Times (12.27.15), “In Arkansas, a centrist Democratic governor, Mike Beebe, found a novel way to expand Medicaid in 2013, using federal money to buy private coverage for 220,000 low-income people through the insurance exchange set up under the health care law. His successor, Gov. Asa Hutchinson, a Republican, said this month that he wanted to continue the expansion while adding some conservative features, including premiums and work incentives. “I opposed and continue to oppose the Affordable Care Act,” Mr. Hutchinson said. But, he added, “we’re a compassionate state, and we’re not going to leave 220,000 people without some recourse.” Ray Hanley, a former director of the Medicaid program in Arkansas, summarized the prevailing sentiment this way: ‘We hate Obamacare and would repeal it tomorrow if we could, but we can’t. So we must do what is best for Arkansas.’”
  • Florida. According to NY Times (1.11.15), “in Florida, where the Legislature has blocked expansion, there is a campaign to amend the state Constitution to require the state to accept federal funds for expansion. It is considered a long shot whether the campaign can gather almost 700,000 signatures by Feb. 1 to put the measure on the ballot during the 2016 presidential campaign.”
  • Kansas. According to KHI News (11.11.15), “three Republicans will not be returning to the House Health and Human Services Committee next year. The reason: Their support for Medicaid expansion…The changes appeared to be part of a major shake-up of committee assignments ahead of the upcoming session and 2016 elections in which all 165 seats in the House and Senate will be contested. In a statement issued through his spokesperson late Wednesday, Merrick confirmed that the reorganization of the health panel was tied to the expansion issue. “Kansans oppose expanding Obamacare, a program that has busted budget after budget in states that have expanded it,” Merrick said. “I will continue to fight to protect Kansans from the disastrous effects of Obamacare.”
  • Kentucky. A surprisingly strong victory (nearly 9 percentage points) by Matt Bevin, a Republican political novice, in the 2015 gubernatorial race has raised questions about whether the state might reverse or roll back its Medicaid expansion.
    • According to New York Times (12.12.15), “more than seven in 10 [72%] residents of Kentucky want their new governor, Matt Bevin, to keep the state’s expanded Medicaid program as it is, according to a new poll from the Kaiser Family Foundation. And more than half of respondents described Medicaid as important for themselves and their families, underscoring the program’s substantial reach in the state and the challenges Mr. Bevin may face if he seeks to scale back or modify it.”
    • According to New York Times (11.28.15), “More recently, including in several interviews since Election Day, [Governor-elect Bevin] has said he would seek federal permission to tighten eligibility for the program and impose more rules and costs on the so-called expansion population… For now, Kentuckians on Medicaid owe nothing for their coverage except minimal co-payments, typically $1 to $4, for certain drugs and services. But Mr. Bevin has repeatedly pointed to Indiana as an example of how Medicaid should work.”
    • According to the New York Times (11.3.15)  “Mr. Obama’s health care law was an especially contentious issue in the race, and some see the Bevin victory as a rebuke to Gov. Steve Beshear, a Democrat, who expanded Medicaid under the measure. An estimated 420,000 Kentuckians, nearly 10 percent of the state’s population, now have coverage as a result. Mr. Bevin, a fierce opponent of the health care law, at first said he would reverse it, but has since softened his position and said he would stop enrolling new people but would not take coverage from those who had it.”
    • Politico (11.4.15) reports: “Al Cross, director of the Institute for Rural Journalism and Community Issues at the University of Kentucky, pointed out that it’s not all up to the governor-elect. “A key thing to remember at this point is the Republican president of the senate, Robert Stivers, made clear in July that the Legislature was going to decide the future of the Medicaid expansion,” Cross said. “It was the very next day that Bevin started talking about doing a waiver like Indiana.”
    • New York Times (11.14.15) reports “But more recently, Mr. Bevin has suggested he would seek federal permission to reshape the program, requiring participants to contribute to the cost of their coverage and possibly scaling back eligibility, something no state has received permission to do under the terms of the health law.”
    • According to Reuters (5.5.17), “last year, Bevin submitted the waiver to restrict Medicaid eligibility by requiring enrollees to work or volunteer at least 20 hours per week and to pay monthly premiums based on income. He’s still awaiting approval. Bevin said he has spoken with several governors about the waiver and has had extensive conversations with Health and Human Services Secretary Tom Price about fast-tracking the approval process in order for other states to quickly adopt similar programs.
      Such conversations are occurring across the country in response to encouragement from the new administration to reform state Medicaid programs, said Alleigh Marre, a Health and Human Services spokeswoman. Louisiana and Wisconsin are considering work requirements for Medicaid enrollees. The Obama administration rejected previous attempts by other states, including Ohio and Arizona, to require work programs and monthly premiums.”
  • Louisiana. A Kaiser Family Foundation/New York Times poll in 2014 found that 66% of Louisiana residents preferred to keep Medicaid as it is rather than expand it. According to the New York Times (1.13.15), “on… his second day in office, Gov. John Bel Edwards signed an executive order expanding Medicaid coverage under the Affordable Care Act,” effective 7.1.16.
    • Gov. Edwards: Enrollment for Medicaid Expansion to Begin on June 1. “Today, Governor John Bel Edwards testified before the Senate Committee on Health and Welfare’s oversight hearing on Medicaid Expansion. During the hearing, Gov. Edwards and Dr. Rebekah Gee, Secretary of the Department of Health and Hospitals (DHH), discussed the positive impact Medicaid Expansion will have on the economy and working citizens of Louisiana. Gov. Edwards also announced that enrollment for expansion will begin on June 1. On Jan. 12, in his first full day in office, Gov. Edwards signed an executive order to expand the Medicaid program in Louisiana.” (Office of the Governor, 4.18.16)
  • Michigan. “Michigan To Reward Medicaid Enrollees Who Take ‘Personal Responsibility. Delayed by state lawmakers, Michigan did not expand Medicaid until the day after the federal online insurance exchange closed March 31 – a move advocates feared would undermine signups…This spring, the Wolverine state became the second after Iowa to offer lower premiums and cost sharing to recipients who agree to do a health risk assessment with their doctor every year and to commit to improve their health by taking steps such as quitting smoking or losing weight.” (Kaiser Health News, 6.11.14)
  • Nebraska. According to New York Times (1.13.15), “Gov. Pete Ricketts, a Republican, remains opposed to expanding Medicaid. But a number of Republican legislators there are pushing a new proposal that would use federal funds to buy private health insurance for about 77,000 low-income people rather than enrolling them in Medicaid. But it is not clear whether the plan can win enough legislative support to override a veto by Mr. Ricketts.”
  • New Hampshire. According to Kaiser Family Foundation, on August 15, 2014, New Hampshire implemented the ACA’s Medicaid expansion through a state plan amendment with coverage through existing Medicaid managed care plans; however,  authorizing legislation required the state  to obtain waiver authority to mandatorily enroll newly eligible adults in Marketplace Qualified Health Plans (QHPs) using Medicaid as premium assistance for the expansion to continue.
  • North Carolina.
    • According to The News and Observer (Raleigh, 11.19.14), “Any plan Gov. Pat McCrory’s administration presents for expanding Medicaid would have a tough time getting through the state legislature. A key House member said Tuesday it would probably be premature to consider expanding Medicaid next year with the future of the federal health care law uncertain. The Republican-controlled Congress is expected to make changes to the Affordable Care Act, under which states had the option to make more people eligible for the government health insurance program.  A Kaiser Family Foundation/New York Times poll in 2014 found that 53% of North Carolinians preferred to keep Medicaid as it is rather than expand it. According to North Carolina Health News (11.24.15), “Although federal regulators are likely to press North Carolina to expand the Medicaid program as part of its reform plan, state officials say there’s currently little talk of expanding the program. That’s according to a presentation given by Medicaid head Dave Richard to the North Carolina Institute of Medicine last week.”
    • According to The News and Reporter (1.6.17), the new governor has announced his intentions to expand Medicaid in the state. “Cooper’s office said he sent a letter to federal regulators altering them of his intentions to seek changes that could provide health care to more than 500,000 people starting in January 2018. He had announced earlier this week his pursuit of Medicaid expansion, which runs against the rising tide on Capitol Hill to get rid of President Barack Obama’s health care overhaul. Leaders of the GOP-controlled state legislature have opposed expansion and on Thursday asked the Centers for Medicare & Medicaid Services to reject Cooper’s request, filed days before Obama leaves office… Cooper is acting even though a 2013 state law prevents him from seeking expanded coverage without the legislature’s formal support. Those legislators say his request is therefore illegal, but Cooper’s office said in a Friday news release that law ‘doesn’t apply to his draft plan.’ The release doesn’t explain why.”
  • Ohio. According to Akash Chougule, Director of Policy at Americans for Prosperity, “When Kasich initially proposed expanding Medicaid under Obamacare in early 2013, he ran into fierce opposition. Not only did the state legislature strip Kasich’s proposed expansion out of the budget – it actually passed legislation that expressly prohibited the expansion from going forward. But Kasich would not be deterred. He used his line-item veto to strike that language and unilaterally expanded Medicaid eligibility. He then threatened to bankrupt the entire Medicaid program if the Ohio Controlling Board, led by a Kasich appointee, didn’t approve additional funding to cover the expansion.”
  • South Dakota.
    • According to NY Times (12.27.15), on 12.11.15, “Republican governor, Dennis Daugaard, announced that he wanted to make 55,000 additional South Dakota residents eligible for Medicaid under the law. ‘I know many South Dakotans are skeptical about expanding Medicaid, and I share some of those sentiments,’ Mr. Daugaard said. ‘It bothers me that some people who can work will become more dependent on government.’ ‘But,’ Mr. Daugaard said, ‘we also have to remember those who would benefit, such as the single mother of three who simply cannot work enough hours to exceed the poverty line for her family.’”
    • According to NY Times (1.11.15), the governor has included Medicaid expansion in his budget.
  • Tennessee. According to NY Times (11.27.14), Gov. Bill Haslam is negotiating with federal officials on an expansion plan that would entail some sort of Medicaid waiver. But according to NY Times (12.27.15), “Gov. Bill Haslam of Tennessee, a Republican, wanted to use federal Medicaid money to extend coverage to 280,000 low-income people. His proposal failed in the spring in the legislature, under attack by conservative groups like the Koch brothers’ Americans for Prosperity, which urged voters to “stop Obamacare in Tennessee.”
  • Utah.
    • According to the NY Times (11.27.14), Gov. Gary Herbert is negotiating with federal officials on an expansion plan that would entail some sort of Medicaid waiver. According to NY Times (12.27.15), “In Utah, Gov. Gary R. Herbert, a Republican, has been trying for two years to expand Medicaid in some way that would be acceptable to state legislators and federal health officials.”
    • According to the NY Times (1.11.15), “In Utah, a Republican governor who had futilely tried to get expansion approved by the Legislature gave up this year and did not include expansion in his budget. Both Republican senators from Utah are opposed to expansion.”
  • Virginia.
    • According to NY Times (6.10.14), “Gov. Terry McAuliffe has lost his battle with the legislature over Medicaid expansion, an enormous retreat from the high expectations he set for a liberal agenda. However, he is thought to be studying how to press the issue by executive action — a legally and politically uncertain course.”
    • According to NY Times (1.11.15), the governor has included Medicaid expansion in his budget.
  • Wyoming.
    • According to the NY Times (11.27.14), Republican governor Matt Mead has proposed a Medicaid expansion plan on 11.26.14 that still requires federal waiver approval. “The expansion plan would also require approval from the State Legislature, which is controlled by Republicans. If lawmakers approve the plan, it will most likely take effect in 2016. The Legislature has already rejected several bills that would have expanded traditional Medicaid. But earlier this year it authorized Mr. Mead to negotiate with the Obama administration on a modified version… The Wyoming plan includes a provision that would terminate Medicaid expansion there if the federal share ever dropped below 90 percent.”
    • According to the NY Times (12.27.15), “Gov. Matt Mead of Wyoming, also a Republican, is urging state legislators to expand Medicaid to cover thousands of low-income people. ‘When I came into office in 2011, I joined other states in a lawsuit challenging the Affordable Care Act, and I still don’t like it,’ Mr. Mead said in an interview. ‘But it’s the law of land. So now I’m trying to be pragmatic, recognizing that we have about 18,000 people who could obtain coverage. We have small hospitals that are struggling. Our federal tax dollars are not headed back to Wyoming, but are paying for health care in Colorado, California and other states.’ Clinching the case for Mr. Mead is the state’s fiscal plight. Revenue is down because of a steep decline in oil and natural gas prices. With the expansion of Medicaid, he said, Wyoming would receive an infusion of federal funds, easing its budget problems.”
    • According to the NY Times (1.11.16), the governor has included Medicaid expansion in his budget.
    • Commentary: Gov. Mead In Wyoming Pushes Obamacare Medicaid Expansion Again. “The Governor is pinning his Obamacare expansion hopes on the false promise of ‘free’ federal money. But there’s one major problem with that: there’s no magic pot of Obamacare money. Every ‘free’ dollar Wyoming spends on Medicaid expansion is a dollar (plus interest) added to the national debt. And to draw down that ‘free’ money, Wyoming will have to pony up a share of the cost itself. Worse yet, the plan not only calls for Wyoming to put up state matching funds in the first year of expansion, but it relies on a funding stream that is likely to go away completely.” Archambault, Josh. (Forbes, 1.11.16)

Medicaid Waivers

Overview

Twenty-four of the 30 states that expanded Medicaid have done so according to the requirements of the Affordable Care Act. But Arkansas, Indiana, Iowa, Michigan, Pennsylvania and Montana have had waivers approved by the Obama administration to expand their Medicaid programs.

The administration has refused to approve waivers that include work requirements for Medicaid coverage. The White House also denied separate proposals by Arkansas, Iowa and Indiana that would have allowed them to drop Medicaid coverage for beneficiaries who make below the federal poverty line if they do not pay their premiums. The Congressional Research Service has summarized (1.30.15) the various  Section 1115 Waivers for ACA Medicaid Expansion that have been approved in each state. These include:

  • Private Insurance Option–Adopted by Arkansas and Iowa.
  • Health Savings Accounts–Adopted by Arkansas, Indiana and Michigan.
  • Premiums–Small premium payments are being required by Arkansas, Indiana, Iowa, Michigan, and Pennsylvania.
  • Healthy Behavior Incentives–Adopted by Iowa, Michigan and Pennsylvania.
  • Non-emergency Medical Transportation–Medicaid will no longer be required to pay for non-emergency transportation for one or more years in Indiana, Iowa and Pennsylvania.

Waivers by State

Arkansas. According to NY Times (8.28.14), “Pennsylvania will join Arkansas and Iowa in using Medicaid funds to buy private coverage for the poor.”

Indiana. According to Tom Miller at AEI, in May 2014, “the state of Indiana unveiled its latest request for a federal Medicaid waiver from the Centers for Medicare and Medicaid Services (CMS) that would allow it to expand its Healthy Indiana Plan (HIP) to cover as many as 559,000 uninsured Hoosiers. For several years, Pence has been seeking Obama administration approval of a modified (HIP 2.0) version of the much smaller HIP experiment that was first launched in 2008.” Miller’s report details how HIP 2.0 compares to the older plan.

  • Manning, Hadley. Mike Pence is headed in wrong direction with Medicaid expansion. Washington Examiner (7.29.14). “Adding more middle-income people to Medicaid not only comes with uncertain and high costs, but sadly it crowds the program, making it less secure for the truly indigent poor.”
  • Archambault, Josh, Jonathan Ingram and Christie Herrera. Mike Pence’s Indiana Medicaid Expansion: Rhetoric vs. Reality. Forbes.com (5.28.14). Authors argue:
    • Pence’s Medicaid expansion is structured and funded like any other open-ended government program rather than a block grant.
    • POWER Accounts under Pence’s Medicaid expansion are nothing like HSAs. There’s no minimum enrollee contribution and the maximum enrollees pay for premiums and savings account contributions are well below levels in HIP.
    • The Pence Medicaid expansion guts Healthy Indiana’s existing skin-in-the-game requirements. The average contributions paid in 2012 under the original Healthy Indiana Plan are up to 165 percent higher than the required contributions under Pence’s Medicaid expansion for the same income groups.
    • The Pence plan creates a new entitlement largely for able-bodied, non-working adults.
    • Like all ObamaCare expansions, Pence’s Medicaid expansion creates a new, permanent entitlement. Federal law classifies the expansion population as a new “mandatory population” for states that opt into the expansion, which authorizes the federal government to take away all federal Medicaid funds if a state were to try to roll back eligibility for that new expansion group. The mandatory nature of this population—once a state opts into expansion—has been codified into regulation and even appears on the forms that states must submit in order to accept expansion.
  • Turner, Grace-Marie. Indiana’s Innovative Medicaid Expansion Idea Could Chart A Path For Major Reform Going Forward. (5.19.14). “This deal is probably as much as Indiana could get in the short term before the existing HIP program is scheduled to expire later this year. It is extremely helpful to have working models of innovative programs as examples of consumer-centered health reform going forward. If Indiana holds the line on any further demands for changes to HIP by the Obama administration – and even demands more flexibility – then Gov. Pence could set the stage for other states to chart a different path forward to reform the flawed, fraud-ridden Medicaid program that fails so many of its enrollees.”

Iowa. Iowa passed the Iowa Health and Wellness Plan on 5.23.13. Supporters argued it was a state-focused free-market Medicaid expansion alternative that would draw “free” money from Washington without having to implement traditional ACA expansion.

  • Ribali, Kristina. Window Dressing: The Iowa Health and Wellness Plan is an ObamaCare Expansion in Disguise. Uncover Obamacare (5.12.14). “Other than a few superficial tweaks and a clever renaming, the Iowa Health and Wellness Plan is a typical ObamaCare Medicaid expansion. It targets the same population of mostly working-age, able-bodied adults with no kids; uses taxpayer dollars to provide essentially the same services as Old Medicaid; is funded from the same pot of ObamaCare Medicaid expansion monies and it similarly ties the hands of policymakers hoping for flexibility from Washington to control costs and improve quality of care.”

New Hampshire. On March 6, 2014, the NH Senate voted to approve a Medicaid expansion (the House has passed a similar bill and Democratic governor is prepared to sign).

Oregon. According to a detailed account in Health Affairs, in 2012, Kitzhaber made a bold contract with the federal government through a Section 1115 Medicaid waiver: Oregon would reduce the rate of growth of per capita spending by two full percentage points, to 3.4 percent per year, in exchange for $1.9 billion in federal funds. The waiver enabled both a significant expansion of the program and full risk capitated contracting for the entire covered population through contracting entities known as Co-ordinated Care Organizations (CCOs).
When the coverage expansion unfolded in the fall of 2013, Oregon’s new risk contracting framework enabled the state to expand its Medicaid population by nearly two-thirds, adding more than 400,000 citizens to coverage. Today, over one million Oregonians participate in the Oregon Health Plan, roughly 25 percent of the state’s citizens.

Pennsylvania. According to NY Times (8.28.14) Pennsylvania is “using federal funds to buy private health insurance for about 500,000 low-income residents starting next year… Pennsylvania’s plan includes requirements for the Medicaid expansion population that go beyond the traditional program. For example, people with annual incomes above the poverty level — $11,670 for an individual — will have to pay premiums equaling up to 2 percent of their household income starting in 2016.”

Rhode Island. The state received a  Global Waiver that essentially provided a large block grant in exchange for a large degree of state flexibility. The program has been highly successful and saved more money than designers anticipated even while expanding utilization.

Wisconsin. “One study, published last year in the Journal of Health Economics, found that charging $10 monthly premiums was associated with enrollment dropping 12 percentage points in Wisconsin’s Medicaid program.”

Wyoming.  According to NY Times (11.27.14), under Gov. Mead’s proposed plan (still to be approved by CMS and state legislature), “those earning 100 to 138 percent of the federal poverty level — for a single person, $11,670 to $16,105 a year — would have to pay monthly premiums. The premiums could range from about $20 to $50 a month, depending on household size and income…People earning less than 100 percent of the poverty level would not have to pay monthly premiums. But they could owe small co-payments for certain services, as could the higher-income group. Those deemed ‘medically frail’ would get Medicaid, which has a slightly more comprehensive benefits package.”

Estate Recovery

According to Medicaid.gov, state Medicaid programs must recover from a Medicaid enrollee’s estate the cost of certain benefits paid on behalf of the enrollee, including nursing facility services, home and community-based services, and related hospital and prescription drug services. State Medicaid programs may also recover for other Medicaid benefits, except for Medicare cost-sharing benefits paid on behalf of Medicare Savings Program beneficiaries. Under certain conditions, money remaining in a trust after a Medicaid enrollee has passed away may be used to reimburse Medicaid.

  • Medicaid Estate Claims: Not the Debt but the Surprise that’s the Problem. “The Duluth News Tribune published an in-depth article on how some people who enrolled in Medicaid through MNsure are making a shocking discovery: The state has placed a claim on their estate for the cost of their Medicaid benefits… Before Obamacare, Minnesota offered three public health care programs to adults with asset limits ranging from $1,000 to $20,000. Obamacare eliminated these asset limits and based eligibility solely on a household’s modified adjusted gross income. Without an asset limit, millionaires are now qualifying for Medicaid… Yet once enrolled in Medicaid, the state slaps a claim on your estate if you’re older than 55…Moreover, the estate claims far exceeded the medical care received by those in the news report. The state argues the claims cover the per-person managed care payment they pay to insurers to administer the plan. But Medicaid is not insurance and it’s highly questionable to impose an estate claim for medical services never received.” (TwinCities.com, 2.23.16)

Access to General Care

Access to Physicians

Medicaid and Emergency Room Use

General Resources

  • Projected, Actual Enrollment for Medicaid Expansion States. This table, compiled by the Associated Press (7.19.15), contains projected and actual enrollment figures for the newly eligible Medicaid population in the 30 states and the District of Columbia that expanded the program under the ACA. Where available, it also provides the estimated and revised cost of paying for the program during the 2017 fiscal year, when states begin paying a share of the expansion.
  • On-line Resources. ObamaCare Watch, Medicaid.
  • Regulations. Federal Register, Medicaid Program; Eligibility Changes Under the Affordable Care Act of 2010; Proposed Rule, Federal Register, Vol. 76, No. 159, 2011, pp. 51148–51199.

News

  • Kaiser Health News. Medicaid. This provides general news about Medicaid, but much relates to Medicaid expansion issues.

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