Medicaid

2019 OPEN ENROLLMENT ENDS (most states)

Time: D H M S

(sigh) Just nine hours ago I posted the following about Kentucky's Medicaid expansion work requirement waiver:

A waiver was approved for Kentucky last spring, but has been (temporarily?) invalidated by court order.

I guess it's a good thing I included the "temporarily" caveat, because just moments ago...

.@CMSGov just re-approved Kentucky’s #Medicaid waiver. https://t.co/2Q16AKQoLS

— Dustin Pugel (@Dpugel) November 21, 2018

Sure enough, here it is:

Over at the Washington Post, Catherine Rampell has an article which confirms EVERYTHING that I and other healthcare wonks have been warning about for months (or years) regarding the real-world impact of imposing work requirements for Medicaid expansion recipients:

...For many low-income families, the Arkansas experiment has already proved disastrous. More than 12,000 have been purged from the state Medicaid rolls since September — and not necessarily because they’re actually failing to work 80 hours a month, as the state requires.

...McGonigal, like most non-disabled, nonelderly Medicaid recipients, had a job. Full time, too, at a chicken plant.

...More important, McGonigal’s prescription medication — funded by the state’s Medicaid expansion, since his job didn’t come with health insurance — kept his symptoms in check.

In the pile-on among Republican-controlled states to impose work requirements on ACA Medicaid expansion enrollees earlier this year, I somehow missed this one:

Wisconsin waiting to hear about requiring work, drug screening for Medicaid recipients

Wisconsin is still waiting to see if the federal government will let it require childless adults on Medicaid to be screened for drugs and work if they are able.

Gov. Scott Walker’s administration also asked in June to add premiums and co-pays for some adults without dependent children on Medicaid, which the federal government also must authorize.

The changes, which Walker said would help people move from public assistance to the workforce, can’t start until a year after approval by the Centers for Medicare and Medicaid Services, or CMS.

...Under Walker’s proposal, childless adults on Medicaid would have to submit to a drug test or enter drug treatment if drug screening called for it.

A few years back I posted an entry which breaks out the income eligibility thresholds for Medicaid and CHIP in every state. I've reposted an updated version below, which also takes into account Basic Health Plan (BHP) eligibility in Minnesota and New York. This comes directly from the Centers for Medicare & Medicaid. Note the footnotes at the bottom. The pink cells on the right indicate that the state has not yet expanded Medicaid under the ACA (Maine and Virginia have passed but note implemented doing so, while Medicaid expansion is on the ballot in Idaho, Nebraska and Utah this November).

As a reminder, here's the 2018 Federal Poverty Level income chart for every state except Alaska and Hawaii (Alaska is 25% higher, Hawaii is 15% higher):

*(OK, it's possible that "no one" actually means "everyone except for me.")

Last summer, both houses of the Nevada state legislature quickly and surprisingly passed a full-blown Medicaid Public Option bill:

I wrote about this back in April, but even I didn't think much of it at the time--I assumed it was more of a symbolic proposal than anything, or that it would die in committee at most. The details are important, of course, but assuming they make sense, this is exactly the sort of approach I would recommend in trying to gradually transition to some type of universal single-payer like system. The biggest questions I'd want answered are 1) What type of coverage does Medicaid actually have in Nevada? It varies widely from state to state, so if NV's is pretty comprehensive, awesome, but if it's skimpy, that's not very helpful; 2) What sort of premiums/deductibles/co-pays would buy-in enrollees be looking at?; 3) What sort of impact would this have on the state budget?; and most significantly, 4) How many Nevada doctors/hospitals would accept these enrollees? Remember, the reason a significant chunk of healthcare providers don't accept Medicaid patients is because it only reimburses them around 50¢ on the dollar compared to private insurance.

Well this could suck. The Times-Picayune reports that up to 60,000 Louisiana residents enrolled in traditional (ie, non-expansion) Medicaid might end up being kicked off the program starting in July:

Louisiana officials will have to notify around 60,000 people who are elderly or disabled in early May that they are slated to lose their Medicaid benefits in July as a result of the Legislature's stalemate over the state budget and taxes.

Gov. John Bel Edwards has proposed eliminating some Medicaid programs that provide long-term care in order to cope with a $994 million budget deficit. The governor said he doesn't want to put forward such cuts, but he doesn't have much of a choice given the state's financial restrictions starting July 1, when the new budget year begins. 

The Louisiana Department of Health is legally obligated to warn people about what might cuts be coming in July two months ahead of time, even if the programs are ultimately spared. 

In a way I guess this was the next "logical" step (via Jesse Cross-Call of CBPP):

Alabama, which has refused to expand Medicaid for low-income adults under the Affordable Care Act (ACA), is now proposing to make work a condition of Medicaid eligibility for very low-income parents, stating that it wants to encourage work. Its proposal, however, actually would penalize work: because Alabama hasn’t expanded its program, those who comply with the new requirements by working more hours or finding a job will raise their income above the state’s stringent Medicaid income limits, thereby losing their Medicaid coverage and likely becoming uninsured.

This just in...I used to track the monthly Medicaid/CHIP reports pretty religiously, but the total numbers have actually stayed fairly stable month to month for the past year or so (mainly because the states which expanded Medicaid under the ACA have mostly "maxed out" by now). This should start changing in Maine later this year as they voted to expand the program via ballot initiative last November, and Virginia may end up expanding Medicaid to up to 400,000 people there as well later this year.

In the meantime, here's where things stood as of the end of 2017, according to CMS:

Highlights from the December 2017 Report

Medicaid and CHIP Total Enrollment

One of the most popular provisions of the Affordable Care Act's Three-Legged Stool's "Blue Leg" is the prohibition of caps on annual or lifetime benefits. When you consider that a baby born prematurely or a cancer patient undergoing chemotherapy can eat up several million dollars worth of care within a few months, this makes perfect sense. Even a moderately wealthy family can be brought down by high medical costs, and a middle class family can be financially wiped out. If you're lower income, don't even get me started.

Naturally, the Trump Administration's response to everything above is "Hmmmmm...screw all that:"

After approving Medicaid work requirements, Trump’s HHS aims for lifetime coverage limits

After allowing states to impose work requirements for Medicaid enrollees, the Trump administration is now pondering lifetime limits on adults’ access to coverage.

Press Release: Governor Cuomo Ensures Medicaid Coverage for DACA Recipients Regardless of Federal Action
If Congress Does Not Act to Protect DACA, New York DACA Recipients will Remain Eligible for State-Funded Medicaid

Governor Andrew M. Cuomo today announced that recipients of the Deferred Action for Childhood Arrivals policy will remain eligible for state-funded Medicaid, regardless of any federal changes to or termination of the program. There are approximately 42,000* DACA recipients in New York, many of whom are at risk of losing their employment-based health insurance if the federal government changes or terminates the program. Under New York law, DACA recipients are considered PRUCOL (Permanently Residing Under Color of Law) and eligible for state-funded Medicaid or CHIP.

Note: This is slightly lower than my own spitball estimate of around 50,000 DACA recipients.

OK, first of all, here's the actual press release from CMS about it:

CMS announces new policy guidance for states to test community engagement for able-bodied adults
Will support states helping Medicaid beneficiaries improve well-being and achieve self-sufficiency

CMS today announced new guidance that will support state efforts to improve Medicaid enrollee health outcomes by incentivizing community engagement among able-bodied, working-age Medicaid beneficiaries. The policy responds to numerous state requests to test programs through Medicaid demonstration projects under which work or participation in other community engagement activities – including skills training, education, job search, volunteering or caregiving – would be a condition for Medicaid eligibility for able-bodied, working-age adults. This would exclude individuals eligible for Medicaid due to a disability, elderly beneficiaries, children, and pregnant women.

In other words, work requirements for Medicaid expansion enrollees are now officially on the table.

I used to track the monthly Medicaid/CHIP enrollment reports issued by CMS, watching as the numbers rose dramatically thanks to ACA Medicaid expansion.

I pretty much stopped doing that about a year ago, however, since the expansion numbers have mostly petered out. ACA Medicaid expansion actually has continued to climb a bit more since January, and is likely somewhere around 16 million people as of now, but it's also been partly cancelled out by a slight drop in standard Medicaid enrollment as the economy has continued to improve in general. In short, there's little reason to keep writing the same update every month.

 

I used to write about Kentucky quite a bit shortly after incoming GOP Governor Matt Bevin made good on his promise to disassemble their beloved and award-winning "kynect" state ACA exchange. I haven't written much about the state since then, however, until now.

Bevin made two major campaign promises while running to replace former Democratic Governor Steve Beshear (who expanded Medicaid and established kynect via executive order): He said he'd kill kynect and get rid of ACA Medicaid expansion. He stuck to his guns on the former, and while it's a damned shame that he did so for a number of reasons (it was working perfectly well, had a high public image and awareness, etc), it didn't cause too much damage, since KY simply shifted to the federal exchange instead (HealthCare.Gov). Enrollment did drop off by over 13% year over year, but a few other states saw similar drops, so the move probably wasn't a major factor.

Every month I post an entry about the official CMS Medicaid enrollment report, documenting the increase in Medicaid enrollment since ACA expansion went into effect. The numbers were increasing dramatically every month for nearly two years, but started slowing down last fall as most of the expansion states started maxing out on their eligible enrollees.

As of August 2016, total Medicaid enrollment continued to quietly increase for a total of 73.1 million people, with 15.7 million of that being mainly due to the ACA (~11 million via official expansion, ~1 million early additions/transfers and ~4 million "woodworkers").

HOORAY! FACE-EATING LEOPARDS FOR EVERYONE!!

I don't write a whole lot about Medicare, since just about all U.S. citizens over 65 are covered by it and therefore don't enroll via the ACA exchanges anyway. However, it does come up on this site from time to time, and a good 55 million or so are enrolled in the program, so this little story might be of some relevance:

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