The State(s) of Medicaid Expansion

In 2012, the Patient Protection and Affordable Care Act (“ACA”) made some sweeping changes to health insurance, but one of the broadest changes was its expansion of Medicaid coverage. Medicaid, a program involving coordination between the federal government and the states, provides healthcare coverage to low-income individuals. Formerly, Medicaid was limited to senior citizens and children with low incomes, pregnant women, those receiving Supplemental Security Income (“SSI”) for disability, and people in a few other, limited categories (depending on the requirements imposed by each state). In accordance with its goal of reducing the number of uninsured, the ACA offered eligibility to all adults with incomes at or below 138% of the federal poverty level. The ACA was intended to apply nationally, but the Supreme Court decision upholding the constitutionality of the ACA also held that states could not be forced to comply with it, making Medicaid expansion optional. This means that states may set their own standards of eligibility for coverage. Currently, 37 states have adopted Medicaid expansion under the ACA while 14 states (Alabama, Florida, Georgia, Kansas, Mississippi, Missouri, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, Wyoming) have not.

Some states sought waivers under Section 1115 of the Social Security Act that allowed them to provide healthcare coverage in ways that are not specifically outlined by Medicaid. States may use Section 1115 waivers to expand coverage, to change the way coverage is delivered, or to alter the kinds of benefits offered, among other things. Seven states (Arizona, Arkansas, Indiana, Iowa, Michigan, Montana, and New Hampshire) have approved these waivers to expand coverage. These waivers allow states to vary who is covered, and how:

• Arkansas, Iowa, and New Hampshire use Medicaid funds to pay private insurers to cover Medicaid recipients.
• Montana’s expansion plan requires those who enroll in Medicaid to pay 2 percent of their income in premiums.
• Michigan similarly requires enrollees to pay premiums based on a percentage of their incomes, although those premiums may be reduced if the enrollees agree to make certain healthy lifestyle choices.
• Indiana requires monthly contributions of $25 from enrollees who are between 100% and 138% of the poverty level and can exclude people from the program if they fail to pay those premiums for six months.
• Arizona is seeking a waiver that would require beneficiaries to work and would impose a five-year cap on benefits.

Of those states that have not chosen to expand Medicaid through the provisions of the ACA or through a Section 1115 waiver, some have seen conflict between the executive and the legislature, whereas others have proposed no plans to account for any gap in coverage. But this is not likely to be the end of the conversation. More than 70 percent of voters in the recent midterms identified healthcare as their most important issue, virtually guaranteeing that Medicaid will remain a vital concern.

Kathleen Davies is a Staff Writer for GetLegal.com. She is a graduate of the University of Michigan Law School and has practiced law and taught legal writing and advocacy.