Introduction and Requirements

OBJECTIVES:

By the end of this module students will be able to:

Describe the history of Medicaid and the effects of Medicaid expansion under the Affordable Care Act (ACA).
List three groups covered by Medicaid and discuss eligibility for Medicaid.
Demonstrate understanding of why reproductive health care is critical to any health care system and what the ACA does and does not provide.
Describe one WWAMI state’s eligibility and service availability for reproductive and children’s health.
Locate and navigate data sets with state level data to be able to find information to counsel women during clerkships about service availability in all WWAMI states.

REQUIREMENTS:

Who has Medicaid and what is its role in their lives? View at least 3 of the 2 minute videos on the Faces of Medicaid to begin to understand the diversity of circumstances that result in Medicaid coverage.
1. http://kff.org/medicaid/video/faces-of-medicaid/
Read Ten Things to Know about Medicaid—expand your knowledge of this program.
1. https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-medicaid-setting-the-facts-straight/
What have been the effects of Medicaid expansion? Learn about the effects of Medicaid expansion.
1. https://www.kff.org/medicaid/issue-brief/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review-august-2019/
Choose a WWAMI state to answer questions for the case study and ungraded quiz (requirement #5). Look at the infographic for the state you choose:
Case study and quiz: Using the state you picked in #4 and the resources listed in the assignment page (or others that you find), answer the questions within the case study (ungraded) quiz.
Submit the module's Statement of Completion.
EVALUATE MODULE and its contribution to your education.
RECORD completion of this module in your UP Tracker!

INTRODUCTION

Welcome to the Medicaid module, about a complex and often changing federal and state health care program. This module gives a general overview of Medicaid and—through a learning case-- explores some aspects of Medicaid that are more specific to the WWAMI region.

History: Medicaid was founded in 1965 as an amendment to the Social Security Act. It is a program designed to provide health insurance to those with limited resources, with funding shared by the individual states and the federal budget. Initially not all states participated, but all have since the 1980s. Until recently it was a program where the federal government matched funds spent by the states--what that meant was that if a state cut Medicaid spending because of budget shortages or priorities, the federal contribution also dropped. Under the Affordable Care Act (2010), the income levels for eligibility for Medicaid were increased to 138% of the Federal Poverty Level, FPL. It was intended for this to be a national program, but in 2012 the Supreme Court ruled that it was optional for states to choose this expansion.

The cost of this expansion of eligibility was fully funded by the federal government until 2016. By 2020 states became responsible for 10% of the cost.

By 2019, 36 states and Washington DC had expanded Medicaid under the ACA. Fourteen states continue to refuse to adopt its expansion, despite the fact that the federal government will always pay 90% of the cost. The income levels for Medicaid qualification can be extraordinarily low. In Texas, for example, Medicaid is only available for parents with a household income up to 7% of the FPL ($1,802/year for a family of 4 in 2019). With the exception of Wisconsin, in all states without expansion, Medicaid is not available to any non-disabled childless adult, regardless of how low their income is. (In WWAMI this pertains to WY).

The coverage gap: When the ACA was written it was expected that people with incomes <100% of the FPL would be covered by Medicaid expansion, and thus no subsidies (help with cost of medical insurance available through the exchanges) are available to anyone with an income less than 100% of the FPL. However, once expansion became optional, low income people in states without expansion became caught in what is called a “coverage gap.” This refers to people who live in states without Medicaid expansion whose incomes are above Medicaid eligibility limits but below the 100% of the FPL where Marketplace premium tax credits kick in. They thus qualify for neither Medicaid nor for subsidies on the exchanges.

Eligibility: There are several ways that people can qualify for Medicaid—all of which vary by state:

--They meet an income requirement—their income is at or less than 138% of the FPL for their family. (States with expansion). As noted above, in states without expansion, the limit is much lower than this.

--In some states only disabled people or people with dependents can qualify, regardless of income.

--Pregnancy increases the income limit for qualification. So some patients may qualify during their pregnancy but not after coverage ends 60 days post partum.

--A second program called CHIP (Children’s Health Insurance Program) increases the income limit for coverage of children. So some families may have coverage for their children but not themselves.

Expansion in WWAMI: In the WWAMI region, Washington, Montana, Idaho and Alaska have some form of expansion.

In 2018 Idaho voted by ballot initiative to participate in ACA expansion. Although a poll in February 2019 showed nearly 75% of voters wished straight implementation, Idaho legislators enacted restrictions to implementation with various provisions, including a 20 hour/week work requirement (or being a student) for participants. Work requirements require extensive tracking and have extremely high administrative costs—not allowed under the ACA unless a waiver is granted to the state. As of August, 2019 the details of implementation are uncertain, because a federal judge blocked the work requirement. Coverage began in January 2020. The state is working to implement a work requirement.

Wyoming is thus the last WWAMI state without expansion. If expansion were to occur, another 20,000 people in WY would have health insurance. The majority of WY voters have opposed increasing health care benefits to poor people. WY allows Medicaid coverage for parents whose income is at or below 54% of the FPL ($11,518/year for a family of 3).