The Medicaid Expansion promotes social justice through equity

The Affordable Care Act (ACA) created a state Medicaid Expansion Initiative to provide health insurance coverage for the remaining population of uninsured adults who suffer from poverty. The program was designed as a primary tool to promote social justice. The population of poor persons has worse health status and worse health care access than do other Americans. The Medicaid Expansion seeks to redress these disparities by promoting equity through expanded health insurance coverage.

The US Supreme Court determined in 2012 that the ACA Medicaid Expansion is at state option rather than mandatory.  Nationally, the initiative has the potential to provide health insurance coverage to about 18 million poor Americans, 40 % of whom have one or more behavioral health conditions. Hence, the Medicaid Expansion is of critical importance for behavioral healthcare, and it is essential that we understand its structure and operation.

Overview

The Initiative.  In a quest to achieve universal coverage, the Medicaid Expansion was designed originally to be an ACA tool to extend health insurance coverage to all uninsured adults who are poor. As a result of the Supreme Court decision, only 26 states and DC are undertaking the Medicaid Expansion in 2014; 4 additional states are undertaking an alternate model (see below); 13 states have determined that they will not undertake the Initiative; and 7 states have not yet made a decision. You can learn more about your own state at: https://www.advisory.com/Daily-Briefing/2012/11/09/MedicaidMap.

Fully 100 % of the cost of the Medicaid Expansion will be paid by the federal government for 2014, 2015, and 2016. Subsequently, this amount will decrease gradually to 90 % by 2020, where it will remain permanently. As such, the Medicaid Expansion is an extremely important tool for providing financial resources to states to address the lack of health insurance among persons who are poor. Currently, these persons use emergency rooms as a primary source of care at great cost to federal, state, and county governments.

Alternate State Plans. The four states with alternateMedicaid Expansion plans are Arkansas, Indiana, Iowa, and Tennessee. Each of these states must seek an 1115 waiver from HHS to undertake its alternate plan. Generally, a common thread among these plans is the purchase of health insurance through private sector plans offered through the state Health Insurance Marketplace. Likely, the most interesting and creative of these alternate plans is that developed by Iowa. The Iowa plan combines traditional Medicaid Expansion for part of the eligible population (up to 100 % of the Federal Poverty Level (FPL)) with private insurance for the remainder of the population (101–133 % FPL). The Iowa Plan also requires participation in a wellness initiative to address common health problems, such as smoking and obesity, in order to maintain state financial support beyond the first year of coverage. See my analysis of the Iowa plan at:   https://www.behavioral.net/blogs/ron-manderscheid/iowa-compromise-reaching-agreement-medicaid-expansion-iowans

Alternative Medicaid Benefit. The insurance benefit available through the Medicaid Expansion is called the Alternative Benefit. This benefit, which varies from state to state, must include the ten insurance benefits available in the Qualified Health Plans offered through the state Health Insurance Marketplaces. A mental health and substance use care benefit must be included, and it must be offered at parity with the medical and surgical benefit. The Alternative Benefit also must include a pharmacy benefit.

Eligible Persons. The Medicaid Expansion is designed to providehealth insurance coverage to all persons between 19 and 64 who are at or below 133 % FPL, currently an income of about $15,200. For states doing the traditional Medicaid Expansion, this will be at no cost to enrollees.

Initial Enrollment Period. States undertaking the Medicaid Expansion in 2014 will begin enrolling persons through their state Health Insurance Marketplaces on October 1 of this year, and the health insurance will become effective on January 1, 2014. Importantly, the enrollment period for the Medicaid Expansion will be continuous going forward.  Currently, HHS is engaged in the initial phases of a very extensive insurance enrollment campaign. Materials from this campaign will become available to you very soon. Only 41 days remain until October 1!

Enrollment Process. The intent is to make it very easy to enroll from anywhere at anytime. Hence, one will be able to enroll online, over the phone, or in-person. Health Insurance Navigators and Enrollment Assisters will be available to facilitate this process. Much more information on this process is available from www.healthcare.gov and www.enrollamerica.org.

Important Related Opportunities for Behavioral Healthcare

Medicaid Expansion Opt-Out States. For states that have opted-out of the Medicaid Expansion for 2014, the state Health Insurance Marketplaces will extend down to 100 % FPL rather than 133 % FPL. Thus, potentially, up to a third of the persons eligible for the Medicaid Expansion in opt-out states can actually be insured through the Marketplaces. We estimate that up to 40 percent of these persons will have a prior behavioral health condition. Many of those who are eligible will lack knowledge of this opportunity. We have a major mission to get the word out to these people in our own communities.

Further, opt-out states have current Medicaid programs that make provision for covering persons who are medically frail. Hence, it will be very important to develop an understanding of this feature of a state’s Medicaid Program, including income limits. Uninsured persons who are medically frail can be referred for Medicaid coverage rather than receive health insurance through the state Marketplace when they meet state criteria.

Finally, in opt-out states, we have an obligation to advocate strongly for health insurance coverage for those persons who will not be eligible for any ACA program. These people will “fall through the cracks’ and will include a significant number with behavioral health and ID/DD conditions. Hence, it will be very important to encourage all uninsured persons to enroll, so that counts can be developed for those who are rejected for Medicaid coverage in opt-out states. 

Federally Qualified HealthCenter(FQHC) Enrollment Sites. FQHCs have received more than $150 million to help people enroll in health insurance. Many poor uninsured persons with behavioral health and ID/DD conditions use FQHCs as their care sites. Hence, we need to help the FQHCs be very successful in reaching out and enrolling this population.

County and City Enrollment Sites. County and city governments operate many programs that will be very useful sites to engage and enroll uninsured persons. These include county and city hospital emergency departments, jails, behavioral health and ID/DD programs, health departments, and public health departments. Many persons with behavioral health conditions will be seen in one or more of these sites. Now is the time to prepare to enroll these uninsured persons as they are encountered in these sites after October 1.

Health Insurance Navigators and Enrollment Assisters. Last week,HHS awarded $67 million in Federal grants to entities in states with Federally Facilitated and State Partnership Marketplaces to fund Health Insurance Navigators (for the list of navigator grant awardees, see:  https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/Downloads/navigator-list-8-15-2013.pdf). These Navigators will help people enroll in health insurance, including the Medicaid Expansion. States with State Operated Marketplaces will fund Enrollment Assisters to perform a similar function. It will be exceptionally important for us to work with the navigators and assisters so that uninsured persons with behavioral health and ID/DD conditions are not overlooked in the outreach process. Peers should play a very large and important role in this process.

Our Next Steps

Without doubt, the Medicaid Expansion provides a once-in-ever opportunity for a very large segment of the uninsured population, all of whom are poor. We must and will take full advantage of this opportunity for uninsured persons with behavioral health and ID/DD conditions.