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Hours after the Supreme Court in 2012 narrowly upheld the Affordable Care Act but rejected the extension of mandatory Medicaid for states, Obama administration officials laughed when asked if it would pose a problem. problem.
During a White House briefing, senior advisers to President Barack Obama told reporters states would be foolish to deny billions of dollars in federal funding to help residents get the security of health insurance.
Flash-forward nearly a decade, and it’s clear to see the consequences of this move. Today, 12 Republican-controlled states have yet to adopt the Medicaid extension, leaving 2.2 million low-income adult residents uninsured.
Tired of waiting for Republican state lawmakers, Congressional Democrats strive to close the Medicaid coverage gap as they forge a set of new national spending that could reach $ 3.5 trillion over 10 years and improve considerably other federal health programs. But the cost raises concerns within the party, and competition for initiatives in the package is fierce.
With Democrats controlling both houses of Congress and the White House, health experts say this may be the only time such a solution away from Medicaid will be possible for many years to come.
“This is one last better chance to do it,” said Judith Solomon, senior researcher at the Left Center on Budget and Policy Priorities.
Here are 6 things to know about Medicaid issues.
1. Who would be helped?
Adults caught in the coverage gap have incomes too high to qualify under their states’ strict eligibility rules that predate the 2010 Health Act, but are below the threshold federal poverty rate ($ 12,880 per year for an individual). When the ACA was created, Congress provided that people earning below the poverty line would be covered by Medicaid, so the law does not provide for any subsidy for coverage in ACA markets.
About 59% of adults in the coverage gap are people of color, according to KFF analysis. Almost two-thirds live in a household with at least one worker.
States that have not extended Medicaid are Alabama, Florida, Georgia, Kansas, Mississippi, North and South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming .
About three-quarters of those in the coverage gap live in four states: Texas (35%), Florida (19%), Georgia (12%), and North Carolina (10%).
2. Why haven’t states increased?
Republicans in those states have listed a litany of reasons. They claim that Medicaid, a federal state program started in 1966 that now covers 1 in 4 Americans, is a failing system that does not improve health, despite dozens of studies to the contrary. Or they say working adults don’t deserve government help with health insurance.
They also complain that it’s too expensive for states to pay their 10% share (the federal government pays the rest), and they don’t trust Congress to keep its funding promises for expanding states.
Every time Medicaid expansion has been passed in a Republican majority state, it has passed – most recently in 2020 in Oklahoma and Missouri.
3. How would the Democrats’ plan work?
The plan of the house has two phases. Under the bill passed by the Energy and Trade Committee, as of 2022, people in the coverage gap with incomes up to 138% of the federal poverty line (approximately $ 17,774 for an individual) would be eligible for grants to purchase federal insurance coverage. Marlet.
Registrants would not pay a monthly premium because the tax credits would be enough to cover the full cost, according to a Solomon analysis. There would be no deductible and only a minimum copayment, like most state Medicaid programs.
Assistance that is not generally available under the ACA would be offered. For example, according to Solomon’s analysis, low-wage workers would not be prevented from signing up for market plans because they have an offer of employer coverage. In addition, people could register at any time of the year, and not just during the registration season in late fall and early winter.
Phase two would begin in 2025. That’s when people with a coverage gap would transition to a Medicaid program run by the federal government and run by managed care plans and third-party administrators.
Registrants would not pay any cost-sharing in the federal Medicaid plan.
4. Would the coverage be as good as if the states adopted the expansion?
It would be very close, Solomon said. The new plan would include coverage for all services defined by law as “essential” health benefits, such as hospital services and prescription drugs.
One difference is that coverage for non-emergency health-related transport services would not begin until 2024. Additionally, during these early years of the plan, some long-term services for medically fragile people typically covered by Medicaid would not be included. , and some screening and treatment services for 19 and 20 year olds would not be offered.
The first phase would also not provide retroactive coverage for the three months preceding the request. Medicaid now covers medical expenses incurred in the three months preceding a person’s request if the person is found to be eligible during those months.
One of the potential benefits of using market plans is that they might have larger physician networks than those associated with Medicaid programs.
5. How much would it cost the government?
The Congressional Budget Office has yet to reveal any estimates, although the price tag would likely run into the billions of dollars.
The federal cost to cover people by helping them buy market plans is higher than it would be if the states had extended Medicaid. That’s because market plans typically pay doctors and hospitals higher fees, making them more expensive, Solomon explained.
6. Could states that have already extended Medicaid cancel this policy and require residents to have coverage under the new setup?
The bill urges states to keep their current Medicaid options. If a state chooses to stop spending funds for the expansion of Medicaid, it may have to pay a penalty based on the number of registrants who transition to the federal program, which can run into the millions of dollars.
KHN (Kaiser Health News) is an editorial independent national newsroom and program of KFF (Kaiser Family Foundation).