Medicaid Expansion

Almost exactly 1 year ago, both Andrew Sprung and I realized that due to an overlap in two provisions of the ACA, a significant chunk of exchange enrollees would actually be eligible for Medicaid instead of a private QHP...if the remaining Republican holdout states were to stop being jackasses and expand the program already.

Why? Because while ACA Medicaid expansion covers people up to 138% of the Federal Poverty Line, QHP financial assistance applies to those with incomes between 100-400% of the FPL. In other words, anyone enrolled in a private exchange policy between 100-138% FPL in a NON-expansion state would automatically become eligible for Medicaid instead the moment that state expanded their Medicaid program via the ACA.

Unfortunately, there was no way of knowing exactly how many people this applied to, because until now, the HHS Dept. only broke out exchange enrollee income brackets into 50% chunks (ie, they listed 100-150% FPL, but not 100-138%).

A few weeks ago I noted that thanks to the election of Democratic Governor John Bel Edwards (with an assist by David Vitter's diaper fetish), up to 375,000 lower-income Louisiana residents became eligible for the ACA's Medicaid expansion provision starting a month earlier than expected (June 1st instead of July 1st).

Enrollment officially started early this morning (not sure if it was right at midnight or if they had to wait until the state offices opened or whatever), and as of around 11:40am...

Gov. Edwards announces that there are already 175,000 Louisianans enrolled in the expanded Medicaid program. #lagov #lalege

— Gov John Bel Edwards (@LouisianaGov) June 1, 2016

Holy Smokes.

Ever since Medicaid expansion officially kicked off in January 2014, the program's enrollment tally started swelling by hundreds of thousands of people every month, and continued to do so right up until July of this year, when it petered out completely:

28,524 additional people were enrolled in July 2015 as compared to June 2015 in the 51 states that reported comparable July and June 2015 data.

Yes, that's right: The net total number of Medicaid/CHIP enrollees went up fewer than 30,000 people in July.

It's worth noting that the improving economy may be a significant part of this. Remember that this is the net number of enrollees; for all I know, 300,000 new people joined the program but 270,000 who were already on it left. Baseline churn is tricky to keep track of.

However, the more likely cause is far simpler: ACA Medicaid expansion has simply finally maxed out in most of the states allowing it, and most of the "woodworker" crowd has presumably finally figured out that they're eligible as well.

Every month the CMS division of the HHS Dept. issues a formal Medicaid/CHIP enrollment report, and pretty much every month (until now) the numbers have grown rapidly. This has been the case even during the "off-season", since there isn't an off season for Medicaid/CHIP enrollment; those eligible for the programs can enroll year-round (on the other hand, promotion/outreach efforts are higher during Open Enrollment, so enrollment does still tend to be more rapid during that period).

As of the end of June, this trend was still continuing: While not hitting the half-million plus rates of many earlier months, nearly 300,000 more people still signed up in June.

292,112 additional people were enrolled in June 2015 as compared to May 2015 in the 51 states that reported comparable June and May 2015 data.

With South Dakota's DAKOTACARE dropping off the ACA exchange and asking for 63% rate hikes, this (potential) development can't come soon enough:

South Dakota may join 30 other states in expanding its Medicaid program if federal officials approve a plan Gov. Dennis Daugaard is set to outline to the nation’s top health and human services administrator in Washington on Tuesday.

The Republican governor is meeting with Health and Human Services Secretary Sylvia Burwell to explain the plan, and the federal government has so far been more open to discussions than in the past, said Tony Venhuizen, chief of staff to Daugaard. The proposal, which is in its early stages, would make about 48,500 South Dakota residents newly eligible for the program.

The twist this time is that the Indian Health Service, which provides healthcare coverage for around 2 million Native Americans nationally, would be involved:


There's not one, not two, not three but four articles I'm reading this morning centering around the same theme: GOP governors who are finally starting to at least consider expanding Medicaid under the Affordable Care Act, but only if the enrollees jump through various hoops in order to qualify:

Sarah Wheaton, Politico:

In nearly a dozen Republican-dominated states, either the governor or conservative legislators are seeking to add work requirements to Obamacare Medicaid expansion, much like an earlier generation pushed for welfare to work.

The move presents a politically acceptable way for conservative states to accept the billions of federal dollars available under Obamacare, bringing health care coverage to millions of low-income people. But to the Obama administration, a work requirement is a non-starter, an unacceptable ideological shift in the 50-year-old Medicaid program and a break with the Affordable Care Act’s mission of expanding health care coverage to all Americans. The Health and Human Services Department has rejected all requests by states to tie Medicaid to work.