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Axios's Bob Herman notes that "Medicaid will be a lifeline for droves of Americans affected by the coronavirus pandemic."
A provision in the second stimulus bill, increasing the federal share of states' Medicaid bills on condition that states refrain from disenrolling any Medicaid enrollees until the crisis subsides, will further incentivize Medicaid enrollment.
Ditto for the income estimates that determine eligibility for marketplace subsidies or Medicaid. The Medicaid standard is simple: your monthly income is above or below the line ($1,468 for an individual, $3,013 for a family of four). Marketplace subsidies depend on estimate of annual income, which will be highly uncertain for many. Kafkaesque as the enrollment process may be, I suspect word will get out: check your current monthly income against Medicaid thresholds, and apply through your state's Medicaid office, so that an annual income estimate required in an ACA exchange does not pull you into weakly subsidized or unsubsidized private insurance.*
While swelling Medicaid rolls will put pressure on state budgets, as Herman notes, that will in turn create pressure for the federal government to pick up still more of the tab, as many have predicted it will have to. Under pandemic pressure, states may also seek waivers to streamline Medicaid enrollment and reduce income verification requirements.
Medicaid's strength for low income people is that it's usually available at zero premium and with zero-to-minimal out-of-pocket expense (some states impose a low premium on some enrollment categories). Its weakness, varying widely by region and specialty, is access to a limited pool of providers. As enrollment pushes deeper into the middle class, or formerly middle class, pressure may grow to expand provider networks, which means paying providers more, bumping up to more or less Medicare rates (rates are already comparable for hospitals).
That means still more federal money. But Medicaid remains the most cost effective way to expand healthcare coverage. While increases in the proportion of the population insured through government programs may put upward pressure on rates, those increases would start from a lower base in Medicaid than in Medicare. Conversely, providers, largely idled by the pandemic if they don't treat infectious disease (and if not drafted for that duty), may be more receptive to accepting new patients at lower rates. The pandemic could be a federal buying opportunity, so to speak.
Since the ACA's core programs were enacted in 2014 (with a few early Medicaid expansions beforehand), Medicaid has been the primary source of improved healthcare access and improved public health. The ACA marketplace is a giant concession to bad Republican ideas: why outsource subsidized coverage to plans paying commercial rates? Why leave pricing and participation to the whims of giant private insurers?
The clear path to providing coverage expansions affordable both to enrollees and the governmental payers has been Medicaid expansion. New York and Minnesota extended this path through the back-door ACA options to create Basic Health Programs, which are essentially managed Medicaid marketplaces offered to people with incomes between 138% and 200% of the Federal Poverty Level. Bumping out the BHP via income-adjusted buy-in offered to people at higher income levels would obviate the need for an individual market as currently structured. States could take this path on their own, via waiver proposals to a Democratic administration, if we ever have another one.
If the pandemic creates a Depression or deep recession, further hollowing out the middle class, pressure for Medicaid access may grow. Expanding Medicaid eligibility with income-adjusted buy-ins is an evolutionary path to a full-blown public option open on affordable terms to all. If Trump weren't a sadistic fraudster whose lifelong m.o. is to give customers nothing of what he's promised, he would have embraced Medicaid expansion as a cheap easy way to fulfill his extravagant healthcare promises.
With buy-ins at higher income levels, Medicaid might become more like CHIP, with provider networks expanding. Once they have Medicaid, lower income people will likely want to keep it. While employer-sponsored insurance is generally perceived to be superior, and does generally provide superior access to providers, it is steadily deteriorating, imposing unaffordable costs on enrollees, particularly low income employees. Medicaid is well positioned to evolve into a viable alternative for all.
Update: As people flood the Medicaid rolls, it's time to end the state option to put a lien on the property of any Medicaid enrollee over age 55 and collect after the enrollee's death.
Update 2: The Trump administration's criminally spiteful decision not to create an emergency Special Enrollment Period for the 38 states using the federal exchange, HealthCare.gov, may further push people toward Medicaid, since Medicaid enrollment is open year-round. 25 states using HealthCare.gov have expanded Medicaid.
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* The ACA exchanges should determine a person eligible for Medicaid if current income is below the Medicaid line, even if annual income is likely to exceed the annual threshold. But as noted here, veteran ACA enrollment assisters are unanimous in preferring application through state Medicaid websites or offices in these circumstances.
Axios's Bob Herman notes that "Medicaid will be a lifeline for droves of Americans affected by the coronavirus pandemic."
The program will pick up many people who lost their income and their health insurance together, as well as people who lost jobs that didn't provide health insurance, and potentially some people who are still working and need medical care but aren't insured.Indeed it will. As of early this year, about 72 million Americans were enrolled in Medicaid's various programs. Based on an old rule of thumb from Georgetown's Edwin Park that I've cited before, enrollment (including CHIP) could reach 85 million or more by the time the pandemic subsides:
Pre-Medicaid expansion, rule of thumb was about 1m Medicaid enrollment increase for every 1pt increase in unemployment rate. Likely significantly higher with many more parents and other adults potentially eligible in expansion states.The ACA marketplace will also absorb some new unemployed. But tax rules that count the CARES Act's $600/week unemployment bump-up as income for the purpose of determining ACA marketplace subsidies, while not counting it in Medicaid/CHIP determinations, will tilt safety net enrollment toward Medicaid in the 36 states plus DC that have enacted the ACA Medicaid expansion. (Conversely, the same tax rule should boost marketplace enrollment and shrink the coverage gap in the 14 nonexpansion states, including Texas and Florida -- unless the crisis drives them to enact the expansion.)
A provision in the second stimulus bill, increasing the federal share of states' Medicaid bills on condition that states refrain from disenrolling any Medicaid enrollees until the crisis subsides, will further incentivize Medicaid enrollment.
Ditto for the income estimates that determine eligibility for marketplace subsidies or Medicaid. The Medicaid standard is simple: your monthly income is above or below the line ($1,468 for an individual, $3,013 for a family of four). Marketplace subsidies depend on estimate of annual income, which will be highly uncertain for many. Kafkaesque as the enrollment process may be, I suspect word will get out: check your current monthly income against Medicaid thresholds, and apply through your state's Medicaid office, so that an annual income estimate required in an ACA exchange does not pull you into weakly subsidized or unsubsidized private insurance.*
While swelling Medicaid rolls will put pressure on state budgets, as Herman notes, that will in turn create pressure for the federal government to pick up still more of the tab, as many have predicted it will have to. Under pandemic pressure, states may also seek waivers to streamline Medicaid enrollment and reduce income verification requirements.
Medicaid's strength for low income people is that it's usually available at zero premium and with zero-to-minimal out-of-pocket expense (some states impose a low premium on some enrollment categories). Its weakness, varying widely by region and specialty, is access to a limited pool of providers. As enrollment pushes deeper into the middle class, or formerly middle class, pressure may grow to expand provider networks, which means paying providers more, bumping up to more or less Medicare rates (rates are already comparable for hospitals).
That means still more federal money. But Medicaid remains the most cost effective way to expand healthcare coverage. While increases in the proportion of the population insured through government programs may put upward pressure on rates, those increases would start from a lower base in Medicaid than in Medicare. Conversely, providers, largely idled by the pandemic if they don't treat infectious disease (and if not drafted for that duty), may be more receptive to accepting new patients at lower rates. The pandemic could be a federal buying opportunity, so to speak.
Since the ACA's core programs were enacted in 2014 (with a few early Medicaid expansions beforehand), Medicaid has been the primary source of improved healthcare access and improved public health. The ACA marketplace is a giant concession to bad Republican ideas: why outsource subsidized coverage to plans paying commercial rates? Why leave pricing and participation to the whims of giant private insurers?
The clear path to providing coverage expansions affordable both to enrollees and the governmental payers has been Medicaid expansion. New York and Minnesota extended this path through the back-door ACA options to create Basic Health Programs, which are essentially managed Medicaid marketplaces offered to people with incomes between 138% and 200% of the Federal Poverty Level. Bumping out the BHP via income-adjusted buy-in offered to people at higher income levels would obviate the need for an individual market as currently structured. States could take this path on their own, via waiver proposals to a Democratic administration, if we ever have another one.
If the pandemic creates a Depression or deep recession, further hollowing out the middle class, pressure for Medicaid access may grow. Expanding Medicaid eligibility with income-adjusted buy-ins is an evolutionary path to a full-blown public option open on affordable terms to all. If Trump weren't a sadistic fraudster whose lifelong m.o. is to give customers nothing of what he's promised, he would have embraced Medicaid expansion as a cheap easy way to fulfill his extravagant healthcare promises.
With buy-ins at higher income levels, Medicaid might become more like CHIP, with provider networks expanding. Once they have Medicaid, lower income people will likely want to keep it. While employer-sponsored insurance is generally perceived to be superior, and does generally provide superior access to providers, it is steadily deteriorating, imposing unaffordable costs on enrollees, particularly low income employees. Medicaid is well positioned to evolve into a viable alternative for all.
Update: As people flood the Medicaid rolls, it's time to end the state option to put a lien on the property of any Medicaid enrollee over age 55 and collect after the enrollee's death.
Update 2: The Trump administration's criminally spiteful decision not to create an emergency Special Enrollment Period for the 38 states using the federal exchange, HealthCare.gov, may further push people toward Medicaid, since Medicaid enrollment is open year-round. 25 states using HealthCare.gov have expanded Medicaid.
----
* The ACA exchanges should determine a person eligible for Medicaid if current income is below the Medicaid line, even if annual income is likely to exceed the annual threshold. But as noted here, veteran ACA enrollment assisters are unanimous in preferring application through state Medicaid websites or offices in these circumstances.
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