Issue #4: Medicaid

On the whole, the Medicaid program is expanding to cover more low-income people, but politics complicate access.

The big picture: Nearly nine years after the Affordable Care Act (ACA) was enacted, 36 states and D.C. have chosen to expand Medicaid to cover people who have incomes up to 138% of the federal poverty level, helping at least 13 million additional low-income people get coverage nationwide. Voters in Idaho, Nebraska, and Utah approved ballot initiatives this past November to expand Medicaid in their states, and Kansas and Maine will likely do so under new Democratic governors. Both red and blue states are getting creative in how they use Medicaid funds to improve health outcomes and reduce costs (see above, Issue #1: Efforts to Address Social Determinants of Health, for more on this).

On the horizon: Democratic control of the United States House of Representatives virtually eliminates likelihood of a legislative repeal of Medicaid expansion or block-granting of the program in 2019, both of which could have been on the table under Republican control. In December 2018, however, a federal court ruled the ACA to be unconstitutional and Congressional leaders on both sides of the aisle are trying to determine the impact of the ruling and their political next steps. The case likely will be heard by the United States Supreme Court for a final ruling. Further, a recent Congressional Budget Office report, released in December 2018, recommends major cuts to Medicare and Medicaid due to the large federal budget deficit. Finally, in January 2018 the Trump administration invited states to implement work requirements to the Medicaid program via 1115 waivers (we discuss the ins and outs of work requirements above in Issue #3: Work Requirements in Public Benefit Programs), which some experts warn could lead to coverage losses. As of January 3, 2019, Arkansas, Indiana, Kentucky, Maine, Michigan, New Hampshire, and Wisconsin had obtained federal approval to implement Medicaid work requirements. Waivers are pending federal approval in Alabama, Arizona, Mississippi, Ohio, Oklahoma, South Dakota, Utah, and Virginia.

We’ll be watching to see how changes to the ACA, federal funding levels for Medicaid and Medicare, and changes to state Medicaid programs play out in 2019, both in terms of augmenting and limiting coverage and access.