Scenario
You are the director of community affairs for the health lobby organization, Pathways to a Healthy America. In 2010, President Barack Obama signed the Affordable Care Act into law. As a result, millions of Americans who were previously uninsured gained access to the healthcare system. One of the initial provisions of the Act required individual states to expand the eligibility criteria for Medicaid. The program’s costs would be absorbed by the federal government at a rate of 100% for the first three years of program participation which would decrease to 90% after 2020, still, considerably higher than previous funding by the federal government. However, in 2012, the Supreme Court ruled the mandate unconstitutional allowing individual states to voluntarily “opt” out of the Medicaid expansion program. As a result of the various states’ decision to “opt” out of the ACA’s Medicaid expansion, millions of adults fell into the critical coverage gap. Your organization represents a state which has decided to forego participation in the ACA expansion program. The decision was met with both praise and criticism.
It has now been a few years since the decision and your organization has gathered information on the impact of the decision in order to advocate for Medicaid reform during the next state legislative session.
You are required to write an advocacy report to state lawmakers in which you advocate for either participating in the original expansion program or participating with conditions (waivers) to address the critical gap in coverage for vulnerable adults in your state. Waivers such as Section 1115 enable for alternative implementation of Medicaid expansion and allow states to impose restrictions which may result in a denial of Medicaid eligibility for individuals who do not meet those restrictions, i.e., work requirements.
Instructions
Research the Medicaid expansion program offered through the Affordable Care Act (ACA) as well as Medicaid reform initiatives using waivers to increase access to Medicaid. Determine, based on your state’s profile, which process (the ACA’s expansion program or the use of waivers) is most beneficial to your state. Include a comprehensive, well-supported recommendation for participation in Medicaid reform using either the ACA’s program or a modified reform process using waivers.
Your advocacy report should describe your state’s (ILLINOIS) current Medicaid program including its eligibility criteria, demographics, Medicaid spending and savings since the ACA’s implementation, and comprehensive details of current or pending waivers. You should also include a discussion (benchmark) on another state’s success with Medicaid reform using your recommended strategy (the ACA’s expansion program or the use of the specific types of waivers for which you propose).
Full Answer Section
Illinois' Current Medicaid Program
- Eligibility: Illinois Medicaid currently covers low-income children, pregnant women, parents, seniors, and people with disabilities. However, many adults fall into a coverage gap due to income exceeding the pre-ACA Medicaid threshold but remaining below the federal poverty level (FPL).
- Demographics: As of 2023, an estimated 480,000 Illinois adults lack health insurance, disproportionately impacting low-income adults, minorities, and rural residents.
- Spending and Savings: While Illinois hasn't expanded Medicaid, ACA subsidies have helped some gain coverage. However, the state loses out on significant federal funding available through expansion.
Impact of Non-Expansion
- Uninsured Rates: Illinois' uninsured rate remains higher than the national average, leading to poorer health outcomes and increased reliance on emergency rooms for primary care.
- Economic Burden: Uninsured adults often delay or forgo essential medical care, leading to higher costs for hospitals and uncompensated care burdens.
- Missed Opportunities: Expansion would create jobs in the healthcare sector and stimulate the state's economy.
Considering Medicaid Reform Options
- ACA Medicaid Expansion:
- Benefits: Full federal funding for the first three years, then 90%, expands coverage to low-income adults, reduces the uninsured rate, improves health outcomes, and generates economic benefits.
- Benchmark: States like Kentucky, which adopted the ACA expansion, saw significant reductions in their uninsured rates and improved health outcomes.
- Medicaid Reform with Waivers (Section 1115):
- Potential Benefits: States can design programs with work requirements or other eligibility restrictions, potentially controlling costs.
- Drawbacks: Waiver approvals can be lengthy, restrictions may discourage enrollment, and federal funding may be lower than full expansion.
- Challenges: Work requirements for Medicaid beneficiaries have faced legal challenges and may not be a sustainable solution.
Recommendation
PTHA strongly recommends that Illinois participate in the ACA's Medicaid expansion program. This approach offers several advantages:
- Unmatched Federal Funding: The federal government covers a significant portion of the costs, alleviating the burden on the state budget.
- Reduced Uninsured Rate: Expansion would significantly reduce the number of uninsured adults in Illinois, improving public health and reducing reliance on emergency care.
- Economic Growth: Expanding Medicaid creates jobs in the healthcare sector and stimulates the state's economy.
- Proven Success: States like Kentucky have demonstrated the effectiveness of expansion in reducing the uninsured rate and improving health outcomes.
Conclusion
Expanding access to healthcare is crucial for the well-being of Illinois residents and the state's economic prosperity. PTHA urges lawmakers to prioritize the health of Illinoisans by enacting the ACA's Medicaid expansion program. This approach offers the most comprehensive and cost-effective solution for closing the coverage gap and ensuring all adults have access to affordable healthcare.
Next Steps
PTHA is committed to working with lawmakers to implement the ACA's Medicaid expansion program effectively. We are available to answer any questions and provide further data to support this critical reform.
Additional Information
This report provides a high-level overview. We encourage further research on the specific details of implementing the ACA's Medicaid expansion program in Illinois.
Sample Answer
Advocacy Report: Expanding Healthcare Access for Illinois Adults
To: Illinois State Lawmakers
From: Pathways to a Healthy America, Director of Community Affairs
Date: April 30, 2024
Subject: Recommendation for Medicaid Expansion or Reform in Illinois
Introduction
Pathways to a Healthy America (PTHA) is a health lobby organization dedicated to expanding access to affordable healthcare. This report analyzes the impact of Illinois' decision to forego the Affordable Care Act's (ACA) Medicaid expansion and proposes a path forward for reform.