The expansion of Medicaid eligibility to nearly all low-income adults is a core component of the coverage provisions in the 2010 Affordable Care Act (ACA). The ACA Medicaid expansion provides a link between new private coverage options available through either Health Insurance Marketplaces or employers and the existing Medicaid program, which previously had many gaps in coverage for adults. Historically, Medicaid eligibility generally was restricted to low income individuals in a specified category, such as children, their parents, the aged, or individuals with disabilities. In most states, adults without dependent children were not eligible for Medicaid. Further, eligibility levels for parents were generally set very low and varied greatly across states. As a result, only 30% of poor nonelderly adults had Medicaid coverage in 2012, compared to 70% of poor children, and uninsured rates for poor adults (42%) were well over twice the national average (18%).1
The expansion of Medicaid, effective in January 2014, fills in historical gaps in Medicaid eligibility for low-income adults and has the potential to extend health coverage to millions of currently uninsured individuals. This expansion essentially sets a national Medicaid income eligibility level of 138% of poverty (about $27,000 for a family of three2) for adults. The expansion was intended to be national and to be the vehicle for covering low-income individuals, with premium tax credits for Marketplace coverage serving as the vehicle for covering people with higher incomes. However, the June 2012 Supreme Court ruling made the expansion of Medicaid optional for states, and as of October 2013, 25 states did not plan to implement the expansion (Figure 1).
Figure 1: Status of State Medicaid Expansion Decisions, as of October 22, 2013
In states that do not expand Medicaid, nearly five million poor uninsured adults have incomes above Medicaid eligibility levels but below poverty and may fall into a “coverage gap” of earning too much to qualify for Medicaid but not enough to qualify for Marketplace premium tax credits. Most of these people have very limited coverage options and are likely to remain uninsured. This brief describes the coverage gap and presents estimates of the population that falls into this situation. An overview of the methodology underlying the analysis can be found in the Methods box at the end of the report, and more detail is available in the accompanying Technical Appendices.
The ACA Medicaid Expansion & the Coverage Gap
Effective January 2014, the ACA establishes a new minimum Medicaid eligibility level of 138% of poverty for non-disabled adults who were not previously eligible for the program. As with current Medicaid, legal immigrants who have been in the country for five years or less and immigrants who are not lawfully present are not eligible for this coverage. The federal government will finance the full cost of the Medicaid expansion for the first three years (2014-2016); after that, the federal government’s share of costs will phase down, reaching 90% in 2020. Nationally, 17 million currently uninsured nonelderly adults may meet the income and citizenship criteria to be eligible for Medicaid after the expansion.3 The number of eligible individuals varies by state, reflecting the income and age distribution in the state as well as the current scope of insurance coverage.
Many of the states moving forward with the Medicaid expansion already offer coverage for parents up to poverty, but adults without dependent children are generally ineligible (see Figure 2). In these states, the expansion extends Medicaid eligibility to all parents and other adults up to the new Medicaid limit. For people with incomes above that limit, other provisions of the ACA—particularly the availability of premium tax credits to purchase individual coverage through the Health Insurance Marketplaces—will facilitate access to affordable coverage.
Figure 2: Median Medicaid Eligibility Limits for Adults as a Percent of the FPL, January 2013 and January 2014
In most states that do not expand Medicaid, however, many people will be left without an affordable coverage option. Medicaid eligibility for adults in states not moving forward with the ACA Medicaid expansion is limited. As of January 2014, the median eligibility level for parents in states not moving forward will be just 47% of poverty, or about $9,400 a year for a family of three (Figure 2). Only four states not expanding Medicaid (Alaska, Maine, Tennessee, and Wisconsin) cover parents up to at least poverty (see Table 1), and eligibility limits in some states are less than 20% of the poverty level (16% in Alabama, 19% in Texas). Of the states not moving forward with the expansion, only Wisconsin will provide full Medicaid coverage to adults without dependent children in 2014.4 5
.. inside WITH NOTE: Table 1: Medicaid Adult Income Eligibility Limits as a Percent of the Federal Poverty Level in States Not Moving Forward with the ACA Medicaid Expansion, January 2014
The ACA envisioned people below 138% of poverty receiving Medicaid and thus does not provide premium tax credits for the lowest income. As a result, individuals below poverty are not eligible for Marketplace tax credits, even if Medicaid coverage is not available to them. Individuals with incomes above 100% of poverty in states that do not expand may be eligible to purchase subsidized coverage through the Marketplaces; however, only about a third of uninsured adults (3 million people) who could have been eligible for Medicaid if their state expanded fall into this income range. Thus, there will be a large gap in coverage for adults in states that do not expand Medicaid (Figure 3).
Figure 3: In states that do not expand Medicaid under the ACA, there will be large gaps in coverage available for adults.
Estimates of People in the Coverage Gap
Nationally, nearly five million poor uninsured adults will fall into the “coverage gap” that results from state decisions not to expand Medicaid (Figure 4 and Table 2), meaning their income is above current Medicaid eligibility but below the lower limit for Marketplace premium tax credits. These individuals would have been newly-eligible for Medicaid had their state chosen to expand coverage. More than a fifth of people in the coverage gap reside in Texas, which has both a large uninsured population and very limited Medicaid eligibility (Figure 4). Sixteen percent live in Florida, eight percent in Georgia, seven percent live in North Carolina, and six percent live in Pennsylvania.
Figure 4: Without Medicaid expansion, 4.8 million uninsured nonelderly adults below poverty may fall into the coverage gap
The population in the coverage gap represents over a quarter (27%) of the uninsured adult population in states that are not expanding Medicaid (Table 2). This share ranges across states, from a low of 18% in Alaska to a high of 37% in Mississippi. This variation reflects not only variation in Medicaid eligibility but also variation in the income distribution of the uninsured by state. There are no uninsured adults in the coverage gap in Wisconsin because the state will provide Medicaid eligibility to adults up to the poverty level in 2014. Looking only at uninsured adults below 139% of poverty in non-expansion states— the income range originally targeted for the Medicaid expansion— about half fall into the coverage gap. The remaining share either may be eligible for Medicaid under non-expansion rules or could receive tax credits to purchase coverage in the Marketplace. The share of the Medicaid-target population that falls into the coverage gap varies by state, from 40% in Alaska (again, 0% in Wisconsin) to 65% in Oklahoma.
.. inside with NOTE: .. Table 2: Number of Poor Uninsured Nonelderly Adults in the ACA Coverage Gap, by State
Among poor uninsured adults, the share that falls into the coverage gap varies across states, reflecting both Medicaid eligibility levels and the income distribution of adults below poverty (Table 1 and Figure 5). Nationally, 86% of poor uninsured adults in states not expanding are ineligible for Medicaid. The share of poor uninsured adults in the gap ranges from a high of 91% in Idaho, North Carolina and Texas to 67% in Alaska. However, in most states not moving forward with the ACA Medicaid expansion, the vast majority of poor adults will remain ineligible for Medicaid coverage. Some of those who are eligible for Medicaid but not currently enrolled may take up coverage as a result of new outreach under the ACA; however, many are likely to remain uninsured.
Figure 5: Medicaid Eligibility for Poor Uninsured Nonelderly Adults In States Not Expanding Medicaid, as of 2014
Conclusion
The ACA was passed with the goal of filling in gaps in the availability of affordable health coverage in the United States. Given particularly high uninsured rates for adults living below poverty, the expansion of Medicaid to all adults up to 138% of poverty is a key component of this effort. In states that expand their Medicaid programs, millions of adults will gain Medicaid coverage under the law. However, with many states opting not to implement the Medicaid expansion, millions of adults will remain outside the reach of the ACA and continue to have limited, if any, option for health coverage: most do not have access to employer-based coverage through a job, few can afford coverage on their own, and most are currently ineligible for public coverage in their state. While a small share may be eligible to purchase subsidized coverage through the new Health Insurance Marketplaces, most have incomes below the poverty level and thus will be ineligible for these premium tax credits. It is unlikely that people who fall into the coverage gap will be able to afford Marketplace coverage: The national average premium for a 40-year-old individual purchasing coverage through the Marketplace is $270 per month for a silver plan and $224 per month for a bronze plan,7 which equates to about half of income for those at the lower income range of people in the gap and about a quarter of income for those at the higher income range of people in the gap. Further, people in the coverage gap are ineligible for cost-sharing subsidies for Marketplace plans and may face additional out-of-pocket costs up to $6,350 a year if they were to purchase Marketplace coverage. Given the limited budgets of people in the coverage gap, these costs are likely prohibitively expensive.
People in the coverage gap are likely to face barriers to needed health services or, if they do require medical care, potentially serious financial consequences. Further, the safety net of clinics and hospitals that has traditionally served the uninsured population will continue to be stretched in these states. Notably, there is no deadline for state decisions about implementing the Medicaid expansion. Millions will be helped by the insurance provisions in the law; however, nearly five million poor adults in states not expanding Medicaid coverage will be ineligible for assistance, while millions more who earn more than they do will receive tax credits to help them pay for coverage in the new insurance Marketplaces. The number and distribution of this population by state will be the subject of a forthcoming Kaiser Family Foundation report.
----- Methods
This analysis uses pooled data from the 2012 and 2013 Current Population Survey (CPS) Annual Social and Economic Supplement (ASEC). The CPS ASEC provides socioeconomic and demographic information for the United Sates population and specific subpopulations. Importantly, the CPS ASEC provides detailed data on families and households, which we use to determine income for ACA eligibility purposes (see below for more detail). We merge two years of data in order to increase the precision of our estimates.
Medicaid and Marketplaces have different rules about household composition and income for eligibility. For this analysis, we calculate household membership and income for both Medicaid and Marketplace premium tax credits for each person individually, using the rules for each program. For more detail on how we construct Medicaid and Marketplace households and count income, see the detailed technical Appendix A available at here .. http://www.kff.org/health-reform/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid .
Immigrants who are not lawfully present are ineligible for Medicaid and Marketplace coverage. Since CPS data do not directly indicate whether an immigrant is lawfully present, we impute documentation status for each person in the sample. To do so, we draw on the methodology in the State Health Access Data Assistance Center (SHADAC) paper, “State Estimates of the Low-Income Uninsured Not Eligible for the ACA Medicaid Expansion.”8 This approach uses the Survey of Income and Program Participation (SIPP) to develop a model that predicts immigration status; it then applies the model to CPS, controlling to state-level estimates of total undocumented population from Department of Homeland Security. For more detail on the immigration imputation used in this analysis, see the technical Appendix B available at here .. http://www.kff.org/health-reform/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid .
As of January 2014, Medicaid financial eligibility for most nonelderly adults will be based on modified adjusted gross income (MAGI). To determine whether each individual is eligible for Medicaid, we use each state’s MAGI eligibility level that will be effective as of 2014.9 Some nonelderly adults with incomes above MAGI levels may be eligible for Medicaid through other pathways; however, we only assess eligibility through the MAGI pathway.10
An individual’s income is likely to fluctuate throughout the year, impacting his or her eligibility for Medicaid. Our estimates are based on annual income and thus represent a snapshot of the number of people in the coverage gap at a given point in time. Over the course of the year, a larger number of people are likely to move and out of the coverage gap as their income fluctuates.
Insurance and Freedom By PAUL KRUGMAN April 7, 2013 .. a bit ..
It goes without saying that Republicans oppose any expansion of programs that help the less fortunate — along with tax cuts for the wealthy, such opposition is pretty much what defines modern conservatism. But they seem to be having more trouble than in the past defending their opposition without simply coming across as big meanies.
Specifically, the time-honored practice of attacking beneficiaries of government programs as undeserving malingerers doesn’t play the way it used to. When Ronald Reagan spoke about welfare queens driving Cadillacs, it resonated with many voters. When Mitt Romney was caught on tape sneering at the 47 percent, not so much. http://investorshub.advfn.com/boards/read_msg.aspx?message_id=86590091
Still, some of the states grudgingly allowing the federal government to help their neediest citizens are placing a condition on this aid, insisting that it must be run through private insurance companies. And that tells you a lot about what conservative politicians really want.
Consider the case of Florida, whose governor, Rick Scott, made his personal fortune in the health industry. At one point, by the way, the company he built pleaded guilty to criminal charges, and paid $1.7 billion in fines related to Medicare fraud. Anyway, Mr. Scott got elected as a fierce opponent of Obamacare, and Florida participated in the suit asking the Supreme Court to declare the whole plan unconstitutional. Nonetheless, Mr. Scott recently shocked Tea Party activists by announcing his support for the Medicaid expansion. http://investorshub.advfn.com/boards/read_msg.aspx?message_id=85264938
You are trying to talk logic? Ok I'll play along - single payer is not just a few years away. So it makes a whole lot of sense for states to develop their own plans because states have their own requirements for insurance or do you think it should be one size fits all? http://investorshub.advfn.com/boards/read_msg.aspx?message_id=92929013
Here's where the real vulnerability in Obamacare has always been: with the states and their inordinate power as heatlh insurance regulators. The ability of Republican state governments to undermine the law has always been a possibility, and always been a concern because of the core structure of the law being state health insurance exchanges. And now, state level Republicans are seeing victories .. http://www.washingtonpost.com/blogs/wonkblog/wp/2013/09/09/two-groups-quit-obamacare-outreach-program/ . Two organizations, one in Ohio and one in West Virginia, have dropped out of a key program that would help enroll millions of the uninsured.
----- Cincinnati Children’s Hospital Medical Center has turned back a $124,419 grant to enroll uninsured people at their main hospital and two satellite locations. Spokesman Terry Loftus said that the hospital decided to decline the funding after Ohio enacted new restrictions in late July that significantly limited who could participate in the program. [...]
West Virginia Parent Training and Information also sent back an award, theirs for $365,758. It was meant to fund “outreach to people with disabilities, people with limited English proficiency and/or limited literacy, people of low socioeconomic status, and people in rural areas,” according to a federal description of the project. [...]
West Virginia attorney general Patrick Morrissey has been a leading critic of the navigator program. He organized in August a letter signed by 13 attorneys general to Health and Human Services that described the navigator program as a “security disaster waiting to happen.” [...]
Morrissey also sent a separate letter to the West Virginia Parent Teaching and Information to solicit specific information from the group in his state. He included eight detailed questions that asked the group to specify whether their navigators would “inform consumers of their data privacy rights” and whether they would require criminal background checks. -----
The new Ohio law prevents any organization that negotiates with health insurers to participate in the navigator program, so hospitals aren't eligible to participate in Ohio. In the West Virginia case, it's obviously a much more direct and specified intimidation campaign by a state official against individual programs.
11 GOP Attorneys General Say Obamacare Fix Is Illegal
The Fiscal Times
By Brianna Ehley 2 hours ago
The White House is facing legal backlash from 11 Republican attorneys general who say the President is breaking the law by making changes to Obamacare without first going through Congress.
West Virginia Attorney General Patrick Morrisey sent a letter .. http://www.wvago.gov/pdf/WV%20Attorney%20General%20-%20ACA%20Rule%20Comments%20CMS%209954-P.pdf .. on Thursday to Health and Human Services Secretary Kathleen Sebelius criticizing the president’s latest executive action that allowed insurance companies to continue offering plans that had been cancelled. The letter, signed by attorneys general from Republican-dominated states including Alabama, Georgia, Idaho, Kansas, Louisiana, Michigan, Nebraska, Oklahoma, Texas and Virginia, called the rule change “flatly illegal under federal constitutional and statutory law.”
.. the idiots will war against Obamacare until they lose their places .. same happened in Australia, and now no party would run for reelection on a platform of wiping our universal healthcare policy ..
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