One of the most important and controversial provisions of the Affordable Care Act is the expansion of health coverage to low-income families through the Medicaid program.
Federal matching funds
States can receive federal matching funds for covering additional low-income individuals and families under Medicaid for whom federal funds were not previously available.
Medicaid expansion was intended to be national, but the June 2012 Supreme Court ruling essentially made it optional for states.
► 39 states, including the District of Columbia have taken advantage of federal funds and expanded their Medicaid programs to provide health coverage to more of their residents.
States will received 100% federal funding for the first three years to support this expanded coverage, phasing to 90% federal funding in 2020.
♦ As of November, twelve states have yet to expand Medicaid under the Affordable Care Act.
Medicaid is not Medicare
Medicaid is intended to help the poorest and most vulnerable of our population. Medicaid provides health coverage for low-income people, families and children, pregnant women, the elderly, and people with disabilities.
♦ 74% of Americans have a favorable view of Medicaid, according to a Kaiser Family Foundation survey. It is likely that this favorable view is because a large number of senior citizens rely on Medicaid to help cover nursing home care.
Before the healthcare law, Medicaid didn’t cover low-income adults without dependent children unless they were pregnant, age 65 or older, or had serious disabilities.
Beginning on January 1, 2014, all children, parents and childless adults who are not entitled to Medicare and who have family incomes up to 133% of the Federal Poverty Level will become eligible for Medicaid — in states that expanded their Medicaid programs.
♦ As of May 2021, 82.8 million people were enrolled in Medicaid and CHIP. This reflects an enrollment increase of 11.5 million since February 2020.
• 48.4% are children enrolled in the Medicaid child program or enrolled in CHIP.
• 51.6% are adults enrolled in Medicaid.
♦ Medicaid is the primary payer for long-term care. Medicaid covers 6 in 10 nursing home residents.
In 2020, Medicaid spent close to 662 billion dollars. Of this amount about 21 percent goes to covering long-term care such as nursing homes.
♦ Of this 662 billion the federal government paid 67.4% and 32.6% was financed by states.
In 2021, Medicaid spending is expected to grow by another 8.4%. A lot of the growth in Medicaid spending has to do with the coronavirus pandemic.
In 2022, Medicaid spending is expected to grow by 7.3%.
People living in states that chose not to expand their Medicaid programs lose.
♦ An estimated 2.2 million people fall into the so-called "coverage gap" — too poor to qualify for subsidies to use at the marketplaces to buy insurance but lacking access to Medicaid because they live in a state that refused Medicaid expansion.
Note — Because of the way Medicaid eligibility is calculated, the qualifying level turns out to be 138% of the Federal Poverty Level. In addition, a few states use a different income limit.
Medicaid primarily uses Federal tax dollars but is administered by the states. Some states also supplement their Medicaid programs with State funds. Because the states have considerable leeway in how they run their programs there can be different requirements depending upon the state you live in.
♦ It is important to note that per CMS guidance, there is no deadline for states to implement the Medicaid expansion.
Federal funding was made available to cover 100% the costs through 2016, with funding gradually dropping off until it reaches 90%.
In 2020, the federal share will drop to 90%. Future years will continue at 90%.
• Wisconsin's governor wants to expand coverage to more people. But Wisconsin's republican-controlled legislature won't go alone.
• Georgia is trying to slide a twisted version of Medicaid expansion before the Biden administration puts the brakes on their plans.
In November 2019, Governor Kemp presented a brief outline that suggests his plan would only cover up to 50,000 people. In Georgia an estimated 408,000 people make less than the Federal Poverty Level but do not qualify for Medicaid.
→ Idaho: Medicaid expansion passed by a vote of 60 to 40. In April 2019, Idaho's legislature passed legislation to make changes to the Medicaid expansion approved by the voters. They wanted to limit expansion up to 100% of FPL. This failed and expansion will proceed on January 1, 2020 up to 138% of FPL. The Governor and the legislature continues to push for a work requirement. Four waiver requests are currently being reviewed by CMS. The Biden Administration is expected to reject any work requirement waivers.
→ Utah: Medicaid expansion passed by a vote of 54 to 46. Medicaid was to be expanded by April 1, 2019 but the Governor and legislature had other plans. Medicaid expansion was pushed out to January 1, 2020 with a work requirement rule added. December 23, 2019, CMS approved Utah's waiver request to include work requirements but did not approve the request to cap enrollment. Medicaid expansion up to 138% of FPL became effective on January 1, 2020. In August 2021, the Biden Administration withdrew Utah's work requirement waiver..
→ Nebraska: Medicaid expansion passed by a vote of 53 to 47. Nebraska's legislature is going all out to delay expansion. It now looks like two years after voters approved the ballot initiative they may finally get something. Expansion is scheduled to start on October 1, 2020. The state continues to submit waiver requests. On October 20, 2020, CMS approved Nebraska's waiver with implementation of some waiver elements to begin on April 1, 2021 and others (including the work requirement) to follow one year later. August 17, 2021 the state withdrew its waiver request.
→ Montana: A ballot initiative to generate funding to continue Medicaid expansion failed by a vote of 53 to 47. Medicaid expansion was going to end in July 2019 but Montana lawmakers reauthorized the expansion for six more years on the condition that there be a work requirement. A waiver was submitted on August 30, 2019. The request is still pending. It is expected the Biden Administration will reject this waiver..
→ Ohio: Republican Mike DeWine was elected governor. He is opposed to the Medicaid expansion put in place by outgoing Republican Governor John Kasich. Ohio received permission in March 2019 to add a work requirement. It was to be implemented in January 2021. In August 2021, the Biden Administration withdrew the work requirement waiver .
♦ Maine voters approved expansion in 2017, but their Republican governor refused to do anything. Governor Janet Mills (D) took office in January and immediately put an end to the stonewalling.
♦ May 30, 2018 The Virginia General Assembly approved Medicaid expansion as a part of a budget bill. Governor Northam signed the budget into law on June 7th. Medicaid expansion became effective on January 1, 2019.
Governor Northam's hands were tied by the Republican controlled legislature which demanded that work requirements be included. Waivers for work requirements were sought but then in 2019 the legislature flipped to the Democrats and waivers were soon canceled.
November 7, 2017 — Voters in Maine approved a ballot referendum to expand Medicaid coverage to 80,000 more residents.
Governor Paul LePage has been one of several GOP governors to block Medicaid expansion.
It is not clear if the people of Maine will get their wish. Just hours after the vote Governor LePage said he would not implement the referendum unless the legislature fully funds the expansion.
June 4, 2018 — A state judge order Governor LePage to get moving on an implementation plan.
July 4, 2018 — Governor LePage vetoed a funding bill for Medicaid expansion. Conservative Republican support was enough to prevent the veto from being overturned. The issue will now go before the Maine Supreme Court.
In August, Maine’s Department of Health and Human Services finally obeyed a court order and filed a Medicaid expansion plan with the federal government. Governor LePage though asked the Trump administration to reject the state’s plan. The plan is still in limbo.
November 6th, Democrat Janet Mills was elected governor with the promise to finally move forward with Medicaid expansion in early 2019.
♦ Citizens in several states, including Idaho, Utah and Nebraska were able to beat back strong Republican opposition to voter initiatives to put the question of Medicaid expansion to a vote.
July 10, 2018 — Republican Senators Lydia Brasch and Mark Christenson filed suit in an attempt to keep the issue off Nebraska's fall ballot. They failed.
November 2018 — Utah voters passed a measure to expand Medicaid to 138% of FPL. The Governor and the legislature are resisting.
Utah's Governor wants to add a work requirement. CMS granted this work related waive on December 23, 2019. Medicaid expansion became effective on January 1, 2020. In February 2021, the Biden Administration began the process to withdraw Utah's work requirement waiver.