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Medicaid on the Eve of Expansion: A Survey of State Medicaid Officials on the Affordable Care Act

Published online by Cambridge University Press:  06 January 2021

Benjamin D. Sommers ,
Sarah Gordon ,
Stephen Somers ,
Carolyn Ingram  and
Arnold M. Epstein
Benjamin D. Sommers
Affiliation:
Harvard School of Public Health
Sarah Gordon
Affiliation:
Department of Social and Behavioral Sciences, Harvard School of Public Health
Stephen Somers
Affiliation:
Center for Healthcare Strategies, Hamilton, New Jersey
Carolyn Ingram
Affiliation:
Center for Healthcare Strategies, Hamilton, New Jersey
Arnold M. Epstein
Affiliation:
Department of Health Policy & Management, Harvard School of Public Health, Office of the Assistant Secretary for Planning and Evaluation, United States Department of Health and Human Services (HHS)
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Extract

As of January 2014, 26 states had chosen to expand Medicaid under the Affordable Care Act (ACA) to cover individuals with incomes up to 138% of the federal poverty level. In these states, Medicaid agencies are facing one of the largest implementation challenges in the program’s history. We undertook a survey of high-ranking Medicaid officials in these states to assess their priorities, expectations, and programmatic decisions related to the coming expansion.

The Medicaid expansion poses major challenges in the domains of enrollment, management of health care costs, and providing adequate access to services for beneficiaries. Previous research has documented that millions of individuals eligible for Medicaid are currently not enrolled and remain uninsured, suggesting that state outreach strategies may underpin the success or failure of the ACA’s coverage expansion.

Type
Article
Information
American Journal of Law & Medicine , Volume 40 , Issue 2-3 , June 2014 , pp. 253 - 279
Copyright
Copyright © American Society of Law, Medicine and Ethics and Boston University 2014

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References

1 Status of State Action on the Medicaid Expansion Decision, 2014, KAISER FAMILY FOUND., http://kff.org/medicaid/state-indicator/state-activity-around-expanding-medicaid-under-the-affordablecare-act/ (last updated Jan. 28, 2014).

2 See discussion infra Parts III.A-C (discussing survey results regarding Medicaid enrollment, costs, and access).

3 Kenney, Genevieve M. et al., Variation in Medicaid Eligibility and Participation Among Adults: Implications for the Affordable Care Act, 49 INQUIRY 231, 236 (2012)CrossRefGoogle ScholarPubMed.

4 Ralph Lindeman, State Medicaid Agencies Reporting Problems in New Exchange-Linked Enrollment System, BLOOMBERG BNA (Oct. 16, 2013), http://www.bna.com/state-medicaid-agenciesn17179878209/.

5 Sommers, Benjamin D. & Epstein, Arnold M., Why States are So Miffed About Medicaid— Economics, Politics, and the “Woodwork Effect,”, 365 NEW ENG. J. MED. 100, 100-02 (2011)CrossRefGoogle Scholar; Sonier, Julie et al., Medicaid ‘Welcome-Mat’ Effect of Affordable Care Act Implementation Could Be Substantial, 32 HEALTH AFF. 1319, 1319-20 (2013)CrossRefGoogle ScholarPubMed.

6 Sommers, Benjamin D. & Epstein, Arnold M., U.S. Governors and the Medicaid Expansion—No Quick Resolution in Sight, 368 NEW ENG. J. MED. 496, 498 (2013)CrossRefGoogle ScholarPubMed.

7 See Baicker, Katherine et al., The Oregon Experiment—Effects of Medicaid on Clinical Outcomes, 368 NEW ENG. J. MED. 1713, 1713-22 (2013)CrossRefGoogle ScholarPubMed; Sommers, Benjamin D. et al., Mortality and Access to Care among Adults after State Medicaid Expansions, 367 NEW ENG. J. MED. 1025, 1025 (2012)CrossRefGoogle ScholarPubMed; Amy Finkelstein et al., The Oregon Health Insurance Experiment: Evidence from the First Year 28-29 (Nat’l Bureau of Econ. Research, Working Paper No. 17190, 2011).

8 PETER J. CUNNINGHAM, CTR. FOR HEALTH SYS. CHANGE, STATE VARIATION IN PRIMARY CARE PHYSICIAN SUPPLY: IMPLICATIONS FOR HEALTH REFORM MEDICAID EXPANSIONS 1-11 (2011); Decker, Sandra L., Two-Thirds of Primary Care Physicians Accepted New Medicaid Patients in 2011-12: A Baseline to Measure Future Acceptance Rates, 32 HEALTH AFF. 1183, 1183-87 (2013)CrossRefGoogle ScholarPubMed; Decker, Sandra L., In 2011 Nearly One-Third of Physicians Said They Would Not Accept New Medicaid Patients, but Rising Fees May Help, 31 HEALTH AFF. 1673, 1673-79 (2012)CrossRefGoogle Scholar.

9 MATTHEW BUETTGENS ET AL., URBAN INST., CHURNING UNDER THE ACA AND STATE POLICY OPTIONS FOR MITIGATION 3 (2012), available at http://www.urban.org/UploadedPDF/412587-Churning-Under-the-ACA-and-State-Policy-Options-for-Mitigation.pdf; Sommers, Benjamin D. & Rosenbaum, Sara, Issues in Health Reform: How Changes in Eligibility May Move Millions Back and Forth Between Medicaid and Insurance Exchanges, 30 HEALTH AFF. 228, 228-36 (2011)CrossRefGoogle ScholarPubMed.

10 See generally Letter from Cindy Mann, Dir., Ctrs. for Medicaid & CHIP Servs., to State Health Official and Medicaid Dir., (May 17, 2013) (on file with Centers for Medicare and Medicaid Services).

11 See Sommers & Epstein, supra note 6, at 496-99.

12 See generally MARTHA HEBERLEIN ET AL., KAISER FAMILY FOUND., GETTING INTO GEAR FOR 2014: FINDINGS FROM A 50-STATE SURVEY OF ELIGIBILITY, ENROLLMENT, RENEWAL, AND COSTSHARING POLICIES IN MEDICAID AND CHIP, 2012-2013 (2013), available at http://kaiserfamilyfoundation.files.wordpress.com/2013/05/8401.pdf; VERNON K. SMITH ET AL., KAISER FAMILY FOUND., MEDICAID IN A HISTORIC TIME OF TRANSFORMATION: RESULTS FROM A 50- STATE MEDICAID BUDGET SURVEY FOR STATE FISCAL YEARS 2013 AND 2014 (2013), available at http://kaiserfamilyfoundation.files.wordpress.com/2013/10/8498-medicaid-in-a-historic-time-oftransformation.pdf.

13 See infra Part V.C. Table 1.

14 See infra Part V.B. Figure 2.

15 See infra Part V.C. Table 3.

16 See infra Part V.C. Table 5.

17 See infra Part V.A.1., for a complete list of states that have chosen to implement the Medicaid expansion. Of note, this survey reports the results of the District of Columbia as a state for simplicity's sake. The Center for Health Care Strategies is a non -profit organization that provides technical assistance to state Medicaid officials across the country.

18 As our study consisted of interviews with public officials about their public roles, it was exempted from review by the Harvard Institutional Review Board (IRB); see also generally 45 C.F.R. § 46 (2013).

19 See, e.g., MICHAEL SPARER, ROBERT WOOD JOHNSON FOUND., MEDICAID MANAGED CARE: COSTS, ACCESS, AND QUALITY OF CARE (2012) available at http://www.rwjf.org/content/dam/farm/reports/reports/2012/rwjf401106; Kenney, Genevieve M. et al., A Decade of Health Care Access Declines for Adults Holds Implications for Changes in the Affordable Care Act, 31 HEALTH AFF. 899, 899-908 (2012)CrossRefGoogle ScholarPubMed; Sommers, Benjamin D. & Epstein, Arnold M., Medicaid Expansion—the Soft Underbelly of Health Care Reform?, 363 NEW ENG. J. MED. 2085, 2085-87 (2010)CrossRefGoogle ScholarPubMed.

20 Sommers, Benjamin D. et al., Lessons from Early Medicaid Expansions Under Health Reform: Interviews with Medicaid Officials, 3 MEDICARE & MEDICAID RES. REV. E1, E1-E23 (2013)CrossRefGoogle ScholarPubMed.

21 See infra Part V.A.2. for the full survey instrument.

22 See KAISER FAMILY FOUND., supra note 1.

23 See infra Part V.A.1.

24 See infra Part V.A.2.

25 See infra Part V.C. Table 1.

26 See infra Part V.C. Table 1.

27 See infra Part V.C. Table 1.

28 See infra Part V.C. Table 1.

29 See infra Part V.C. Table 1.

30 See infra Part V.C. Table 1.

31 See infra Part V.C. Table 1.

32 See infra Figure 1.

33 See infra Part V.C. Tables 1, 2.

34 See infra Part V.C. Table 2.

35 See infra Part V.C. Table 2.

36 See infra Part V.C. Table 2.

37 See infra Part V.B. Figure 2.

38 See infra Part V.B. Figure 2.

39 See infra Part V.C. Tables 3, 4.

40 See infra Part V.C. Tables 3, 4.

41 See infra Part V.C. Table 3.

42 See infra Part V.C. Table 4.

43 See infra Part V.C. Table 4.

44 See infra Part V.C. Table 4.

45 See infra Part V.C. Table 4.

46 See infra Part V.C. Table 3.

47 See infra Part V.C. Table 3.

48 See infra Part V.C. Table 3.

49 See infra Part V.C. Table 4.

50 See infra Part V.C. Table 5.

51 See infra Part V.C. Table 5.

52 See infra Part V.C. Table 5.

53 See infra Part V.C. Table 5.

54 See infra Part V.C. Table 5.

55 See infra Part V.C. Table 5.

56 See infra Part V.C. Table 5.

57 This survey item is not reported in the Tables.

58 See infra Part V.B. Figure 3.

59 See infra Part V.B. Figure 3.

60 See infra Part V.B. Figure 3.

61 See Mann, supra note 10, at 3.

62 Hwang, Ann et al., Creation of State Basic Health Programs Would Lead to 4 Percent Fewer People Churning Between Medicaid and Exchanges, 31 HEALTH AFF. 1314, 1314 (2012)CrossRefGoogle ScholarPubMed. Section 1331 of the ACA allowed states to create BHPs to cover individuals who might fall just above and below the Medicaid eligibility line, and also to cover individuals who were lawfully present not citizens with incomes below 133% of the federal poverty line. Patient Protection and Affordable Care Act of 2010 § 1331, 42 U.S.C. § 18051 (2012).

63 Rosenbaum, Sara & Sommers, Benjamin D., Using Medicaid to Buy Private Health Insurance— The Great New Experiment?, 369 NEW ENG. J. MED. 7, 7 (2013)CrossRefGoogle ScholarPubMed.

64 See infra Part V.C. Table 6.

65 See Infra Part V.C. Table 6.

66 See infra Part V.B. Figure 1 (illustrating that approximately 45% of officials voted possible, 23% voted likely, and 5% voted nearly certain).

67 Cf. STAN DORN & MATTHEW BUETTGENS, URBAN INST., NET EFFECTS OF THE AFFORDABLE CARE ACT ON STATE BUDGETS 1 (2010), available at http://www.urban.org/UploadedPDF/1001480-Affordable-Care-Act.pdf (asserting that state costs are expected to increase due to an expected woodwork effect and a gradual decline in the federal share beginning in 2017, even though newly eligible adults will be covered by the federal government from 2014-2016).

68 Id. at 1.

69 See Federal Financial Participation in State Assistance Expenditures for Fiscal Year 2014, 77 Fed. Reg. 71,420, 71,422 (Nov. 30, 2012) (reporting a minimum match rate of 50.00% for Alaska and other similarly situated states and a maximum match rate of 73.05% for Mississippi).

70 See Sommers, supra note 6, at 496, 498-99 (noting that some governors expressed concern that the federal government will “scale back its share of Medicaid spending” in the future).

71 See infra Table 5 (reporting that 36% of the officials believe that the Medicaid expansion will overload the healthcare system).

72 See Joynt, Karen E. et al., Insurance Expansion in Massachusetts Did Not Reduce Access Among Previously Insured Medicare Patients, 32 HEALTH AFF. 571, 576 (2013)CrossRefGoogle Scholar (finding that the insurance expansion did not have a negative effect on preventable hospitalizations).

73 See infra Part V.C. Table 5 (reporting that 50% of the officials believe that a lack of specialists was one of the greatest barriers to care).

74 See infra Part V.C. Table 5 (reporting that 10% of the officials believe the payment increase would have a “large impact” on physician participation rates).

75 David Bricklin-Small & Tricia McGinnis, Improving the Medicaid Primary Care Rate Increase, COMMONWEALTH FUND BLOG (May 16, 2013), http://www.commonwealthfund.org/Blog/2013/May/Ways-to-Improve-Upon-the-Medicaid-Primary-Care-Rate-Increase.aspx (“[I]t is not clear whether the gains [of the payment rate increase] will extend beyond the increase's two-year time frame.”).

76 Sommers, Anna S. et al., Physician Willingness and Resources to Serve More Medicaid Patients: Perspectives from Primary Care Physicians, 1 MEDICARE & MEDICAID RES. REV. E1, E14 (2011)CrossRefGoogle ScholarPubMed.

77 See infra Part V.C. Table 5 (reporting that 45% of the officials believe that churning was one of the greatest barriers to care for new Medicaid beneficiaries).

78 This item is unreported in Part V, infra.

79 See infra Part V.C. Table 6 (reporting that 41% of the officials believe that coordinating coverage with the exchange will be the biggest implementation challenge of the 2014 expansion).

80 See infra Part V.B. Figure 3.

81 See infra Part V.C. Table 1 (reporting that 76% of officials believe that the “[p]redicted take - up of Medicaid among newly-eligible adults” is between 50% and 75%).

82 See Kenney, supra note 3, at 244-45 (reporting that the eligible adult enrollment est imates by state were highly variable, ranging from 51% to 93%); see also Sommers, supra note 19, at 2085 (reporting that the eligible adult enrollment estimates were highly variable, ranging from 44% to 88%).

83 See Sommers, Benjamin D. et al., Reasons for the Wide Variation in Medicaid Participation Rates Among States Hold Lessons for Coverage Expansion in 2014, 31 HEALTH AFF. 909, 912 (2012)CrossRefGoogle ScholarPubMed (finding that the “strongest predictor of Medicaid take-up was category of eligibility” and that the category of disabled adults signaled a significantly higher probability of Medicaid enrollment).

84 See GENEVIEVE M. KENNEY ET AL., URBAN INST., OPTING IN TO THE MEDICAID EXPANSION UNDER THE ACA: WHO ARE THE UNINSURED ADULTS WHO COULD GAIN HEALTH INSURANCE COVERAGE? 1 (2012), available at jrawww.urban.org/UploadedPDF/412630-opting-in-medicaid.pdf.

85 See infra Part V.C. Table 1.

86 See infra Part V.C. Table 1.

87 See Sommers, supra note 19, at E14.

88 See infra Part V.B. Figure 1.

89 See infra Part V.B. Figure 1.

90 See Nick Budnick, Oregon Cuts Tally of People Lacking Health Insurance by 10 Percent in Two Weeks, OREGONIAN (Oct. 17, 2013), http://www.oregonlive.com/health/index.ssf/2013/10/oregon_has_cut_tally_of_those.html.

91 See infra Part V.C. Table 6.

92 See infra Part V.C. Table 2.

93 Martina Stewart, Administration: Obamacare Website Working Smoothly, CNN (Dec. 1, 2013), http://www.cnn.com/2013/12/01/politics/obamacare-website/.

94 Robert Pear, State Officials Cite Technology Problems on Health Insurance Sites, N.Y. TIMES (April 3, 2014), http://www.nytimes.com/2014/04/04/us/state-officials-cite-technology-problems-onhealth-insurance-sites.html?_r=0.

95 See infra Part V.C. Table 5.

96 See infra Part V.C. Table 3.

97 See SPARER, supra note 18, at 3.

98 See infra Part V.C. Table 5.

99 See infra Part V.C. Table 3.

100 See infra Part V.C. Table 5.

101 See infra Part V.C. Table 1.

102 Of note, this is the full survey instrument, excluding the description of the study and background information for participants. Not all items below were presented in the paper due to space constraints.

103 Percentages for each question exclude item non-response. Full survey sample size, N=23. IT: Information Technology; CHIP: Children's Health Insurance Program; SNAP: Supplemental Nutritional Assistance Program, formerly known as “food stamps.”

104 Percentages for each question exclude item non-response. Full survey sample size, N=23

105 Percentages for each question exclude item non-response. Full survey sample size, N=23.

106 Percentages for each question exclude item non-response. Full survey sample size, N=23.

107 Percentages for each question exclude item non-response. Full survey sample size, N=23. “Federal Exchange” includes states with Federal-State Partnership Exchanges (5) and the Federally-Facilitated Exchange (1). P-value is based on chi-square test comparing all categories, by federal versus state-based Exchanges.

108 Percentages for each question exclude item non-response. Full survey sample size, N=23.

109 Percentages for each question exclude item non-response. Numbers may not sum to 100% due to rounding. 3 states answering that they expect the Medicaid expansion to be “Budget Neutral” were excluded from this stratified analysis, but are included in the full sample data in reported in Table 3.

110 Percentages for each question exclude item non-response. Full survey sample size, N=23. Totals may not sum to 100% due to rounding.

111 Officials were asked to select up to two options for this item. Percentages for each question exclude item non-response. Full survey sample size, N=23. Totals may not sum to 100% due to rounding.