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Despite COVID-19, Some States Still Blocking Medicaid Expansion, Seeking Other Restrictions

March 31, 2020 at 10:15 AM

While some states have responded to COVID-19 by quickly using Medicaid’s flexibilities to help people maintain their coverage and remove barriers to care, others are instead restricting Medicaid. Some still aren’t implementing the Affordable Care Act’s (ACA) Medicaid expansion, even though they could collectively make up to 4.4 million low-income uninsured adults eligible for coverage by doing so, while others are advancing or proposing new restrictive policies that will take away people’s coverage. These states should swiftly reverse course, especially since the pandemic and almost-certain recession are making health coverage more important than ever.

Oklahoma Governor Kevin Stitt took the most dramatic restrictive step on March 16, releasing for state public comment the first waiver request under the Trump Administration’s recent guidance that invites states to seek federal waivers to convert parts of their Medicaid programs into harmful “block grants.” When grassroots efforts to put a Medicaid expansion on the ballot this year gathered unprecedented signatures, the governor agreed to implement the expansion, and it’s slated to take effect July 1. But instead of a straightforward expansion, which would provide Medicaid coverage to an estimated 200,000 Oklahomans — a number that would likely grow during the coming recession as people lose jobs and income — the governor’s waiver plan would:

  • Take coverage away from people who don’t meet a work requirement. Governor Stitt proposes to take coverage away from people who don’t report 80 hours of work each month, even though federal courts have repeatedly struck down similar waivers in other states.

    While Oklahoma estimates that only 5 percent of beneficiaries will lose their coverage, the actual loss will almost certainly be far higher. When Arkansas implemented a work requirement in 2018 — which was less stringent than what Governor Stitt proposes — more than 18,000 people, or nearly 1 in 4 of those subject to the rules, lost their coverage. In New Hampshire nearly 17,000 people — about 40 percent of those subject to the rules — were on track to lose their coverage before policymakers suspended the program. And in Michigan, more than 80,000 people — about a third of those subject to the rules — were in danger of losing coverage before a federal judge suspended the state’s policy.

  • Take coverage away from people who can’t pay premiums. Oklahomans newly eligible for coverage through the Medicaid expansion wouldn’t get it until they make a monthly premium payment, and any missed payments would end their coverage. Studies have consistently found that requiring premium payments causes people to lose Medicaid coverage and become uninsured.

  • Make it harder for people to enroll in coverage. Oklahoma’s waiver proposal would eliminate hospital presumptive eligibility, which lets qualified entities like hospitals and other providers enroll people in coverage. As we’ve explained, states should expand their use of this option right now, since it offers an expedited pathway to enrollment during a public health emergency.

  • Make it harder for people to get to the doctor. The proposal would eliminate non-emergency medical transportation (NEMT), an important benefit for low-income adults, who often face transportation barriers. People rely on NEMT to reach appointments for behavioral health services, dialysis, preventive services, and specialist visits, among others.

  • Put Oklahoma’s federal funding for the Medicaid expansion at risk. The pandemic and likely recession illustrate the importance of Medicaid’s funding structure: as more people sign up for Medicaid or per-person costs rise when people need expensive care related to COVID-19, federal funding automatically rises to cover most of the extra costs. Yet Oklahoma seeks to become the first state to impose a limit on its federal Medicaid dollars and put itself on the hook for 100 percent of the costs from higher-than-expected per-person costs for expansion enrollees.

Meanwhile, lawmakers in other states blocked efforts to expand Medicaid coverage or are moving forward with policies to take Medicaid away from people unable to meet work requirements.

  • In Kansas, a small group of Republican legislators blocked a bipartisan Medicaid expansion bill that would make an estimated 150,000 Kansans eligible for Medicaid — a number that would likely grow in a recession.

  • In Nebraska, voters passed a ballot initiative in 2018 to expand Medicaid, but Governor Pete Ricketts has refused to implement a straightforward expansion, insisting on a complex alternative that won’t be in place until October and will likely deprive many Nebraskans of access to needed care. Even with COVID-19, the governor has refused calls to accelerate the expansion, which would provide Medicaid to approximately 80,000 Nebraskans — again, likely more in a recession.

  • Utah voters also expanded Medicaid through a ballot initiative in 2018 but, after delaying the implementation of a full expansion, Governor Gary Herbert and state legislature insisted on adding a policy taking coverage away from people who don’t meet work requirements. Utah hasn’t altered its policy in response to COVID-19 and the coming recession, even though the policy requires people to work 120 hours a month or report 48 job searches in three months in order to maintain their coverage.


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