The expanding role of Medicaid in US health care

Mostly taken from “The expanding role of Medicaid in US health care: A research roundup,, Kerry Dooley Young. May 2023.”

I have added commentary to this report. I do have another report on Medicaid which I have to deep dive to make shorter sense of it. This report includes information going back to Obama’s introduction of the PPACA and the impact of it on Medicaid. It offers information to a reader which they may not be aware of or have forgotten.

Originally published in July 2020. In light of the Republicans’ debt ceiling negotiations with the Biden administration in 2023, involving discussions of a federal Medicaid work requirement, the report is current as of May 24 with some updated statistics. This is a partial of the report. A list of additional studies as recently as April 2023 are this site.

The two largest U.S. health plans share a birthday, July 30, 1965, but they have different roles and public images.

law signed by President Lyndon B. Johnson created Medicare, which serves people age 65 and older, and Medicaid, which covers people considered to be poor by government standards. Both programs also cover people with disabilities, contributing to overlap between Medicaid and Medicare. About 12.2 million people of the about 60 million people enrolled in Medicare in 2018 also had Medicaid coverage.

People tend to remain enrolled in Medicare. In 2022, 55.5 million of the the 63.8 million participants were age 65 and older, according to the 2022 Medicare trustees report. The rest of the enrollees qualified due to disabilities.

Not so with Medicaid, where there is more churn.

For example, about 86.7 million people were covered by the state-federal program at some point during fiscal 2018, according to a December 2019 report from Medicaid and CHIP Payment and Access Commission (MACPAC). But fewer might be covered by the program at any given point in the year, as can be tracked through Medicaid’s website.  (The program posts a monthly snapshot of recent enrollment as well as releasing more extensive data.)

People gain Medicaid coverage when they lose jobs — for instance, during the recession stemming from the COVID-19 pandemic — and drop it when they become employed again. Some people with disabilities also rely on Medicaid coverage while waiting to qualify for Medicare.

While Medicaid is a safety-net program for many Americans, Medicare is more of an aspiration, which enjoys a significant base of bipartisan support.

“You couldn’t move my mother out of Medicare with a bulldozer,” then House Energy and Commerce Chairman Billy Tauzin, a Louisiana Republican, said in 2003, while working on the last major expansion of the federal health program.

“She trusts in it, believes in it. It’s serves her well.”

But there’s a sharp partisan divide about Medicaid. There were no Republican votes for the 2010 Affordable Care Act (ACA), which set the stage for a major expansion of Medicaid that’s still unfolding. Instead Republicans have since tried repeatedly to repeal the ACA, while also reviving in recent years attempts to convert federal funding of Medicaid from an open-ended commitment based on formulas to more limited support though block grants.

GOP’s unsuccessful ACA repeal bids in 2017 foundered, though, in part due to growing support for Medicaid, according to Richard Sorian, a former assistant secretary for public affairs at the Department of Health and Human Services in the Obama administration. Sorian looked at how the 2014 expansion had allowed more people to get access to health care in several states with Republican governors, such as Ohio, as well as in those dominated by Democrats.  Richard Sorian writes;

“For most of its history, Medicaid took a back seat to Medicare, the health benefits program for seniors and others. But many more are leery of touching the program and facing the wrath of the people who elected them.”

Adding . . . some politicians still seek Medicaid budget cuts.

A few statistics show how Medicaid underpins much of U.S. health care.

  • About 1 in 5 Americans get health insurance through Medicaid. It is run by the states with federal financial support and oversight. As of January 2023, more than 85.9 million people in the U.S. were in Medicaid. This according to the latest data posted by the Centers for Medicare and Medicaid Services (CMS). There were about 7 million participants in the Children’s Health Insurance Program (CHIP), considered a sister initiative to Medicaid.
  • Medicaid paid for 43% of all births in the U.S. in 2018, while private insurance plans paid for 49%. Policymakers now are looking to expand Medicaid coverage to try to lower the high rate of maternal mortality in the United States. There are bills pending in Congress that would require Medicaid coverage of new mothers from a 60-day period to the entire year following giving birth.
  • Medicaid is the largest U.S. purchaser of what it calls behavioral health services, which include mental health treatment and services to treat addiction and substance abuse.
  • Medicaid is the primary tool through which the Affordable Care Act (ACA) of 2010 expands the public’s access to health care.

News coverage of the federal government’s implementation of the ACA in 2014 focused heavily on hitches with the startup of the online state and federal exchanges through which people who did not get health plans from their employers can buy medical coverage. These were primarily intended to help people whose employers do not offer health plans. Many people get subsidies to purchase their insurance on these exchanges. Without this help, they might not be able to afford insurance.

About 11.4 million people were covered by these health plans sold on the exchanges for 2020, according to a report from the Centers for Medicare and Medicaid Services (CMS).

These include plans sold by for-profit companies as well as ones from nonprofit insurers.

By late 2018, about 15.1 million people were using Medicaid due to expansion created by the ACA, CMS reported.

States have varied eligibility criteria, including income cutoffs, for Medicaid. Before the ACA, many states largely excluded adults who do not have disabilities,  no matter how little they earned.

President Barack Obama and congressional Democrats intended for all states to raise their Medicaid eligibility requirements to allow adults who work but have incomes just above the federal poverty level to get health insurance. CMS last year authorized Utah’s Medicaid expansion, which will allow coverage for single people with annual income of as much as 138% of the federal poverty level ($17,608). For a family of four, this income cutoff would be $36,156.

Under the ACA, states initially were required to set their cutoff for Medicaid eligibility at a level allowing people with household incomes as high as 138% above the federal poverty level to enroll. It is important to note the actual text of the ACA sets this level at 133%, other provisions of the law nudged the cap to 138%.

In 2012, the U.S. Supreme Court decided that states could choose whether they wanted to raise the threshold for Medicaid eligibility under ACA. In an effort to encourage states to raise their income thresholds to allow more people to qualify for Medicaid, the federal government offered to cover the majority of the cost of covering these new enrollees.

Many Republican state governors initially balked at the offer and GOP political candidates campaigned on pledges to repeal the ACA.

Several Republican leaders, including Gov. Gary Herbert of Utah and then Indiana Gov. Mike Pence, later took the federal government up on its offer. The U.S. opioid epidemic helped persuade GOP holdouts to expand Medicaid. As of May 2023, 10 states have not taken formal action to expand Medicaid, according to a tally kept by the Kaiser Family Foundation.

In some states expanding their Medicaid coverage, Republican governors added conditions for people who are able to enroll thanks to increased income thresholds, including payments of premiums. Congressional and state Democrats have objected to Republican attempts to add work requirements to Medicaid participation for adults who do not have disabilities. They have argued that many people added as a result of the expansion already work and documenting employment is a significant administrative burden.

To help journalists report on Medicaid, we’ve summarized a few studies below to help reporters understand the key debates happening about this program.

At the heart of Medicaid research are persistent questions about how well the massive state-federal health program works. Studies published to date show mixed results on questions of whether having Medicaid coverage helps participants improve or maintain their health.

For example, one study found middle-aged people who live in states that expanded Medicaid under the ACA are less likely to die of heart disease.

But discussions about Medicaid often quickly loop back to the somewhat surprising findings of a 2008 experiment in Oregon involving Medicaid. After Oregon officials found they had funds for a limited expansion of the state’s Medicaid program, they used a lottery to select about 30,000 people from a waiting list of almost 90,000. This approach allowed economists a rare opportunity to study the effects of Medicaid coverage in a group of people randomly selected to enroll in the state-federal health plan.

Some findings from studies of the Oregon experiment disappointed advocates for Medicaid expansion. These findings include research that seems to contradict a common theory that people newly enrolled in Medicaid  would use emergency rooms less often for basic health care needs if they could afford to see a primary care doctor by participating in Medicaid. Visits to a primary care clinic cost significantly less than emergency room visits.

In recent years, many researchers have sought to assess the early impacts of the ACA’s Medicaid expansion. The results of the Oregon experiment cast doubt about the possible benefits of Medicaid coverage for a group that had been randomly selected to receive coverage, writes Sarah Miller, an assistant professor at the University of Michigan’s Ross School of Business, and her co-authors in a 2019 paper.

“The inconclusive nature of these results has led to skepticism among some researchers, policymakers, and members of the media as to whether Medicaid has any positive health impacts for this group.

In their paper, though, Miller and her co-authors estimate Medicaid expansion may have prevented 4,800 deaths in their sample population among people ages 55 to 64, or roughly 19,200 fewer deaths over the first four years alone. Miller and her co-authors also offer an estimate of what many states’ decisions against Medicaid expansion meant for their citizens.

“Our estimates suggest that approximately 15,600 deaths would have been averted had the ACA expansions been adopted nationwide as originally intended by the ACA.”

In another report Miller and her associates did conclude a broader access to Medicaid appeared to lower the mortality rate in a study focused on people ages 55 to 64, Miller and her co-authors find. An additional University of Michigan study on the relationship between Medicaid enrollment and mortality found a 0.13 percentage point decline in annual mortality, a 9.3% reduction over the sample mean, associated with Medicaid expansion. The effect is driven by a reduction in disease-related deaths and grows over time.