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Partial Medicaid Expansions Fall Short of Full Medicaid Expansion With Respect to Coverage and Access to Care

August 13, 2018

Millions of low-income adults with incomes up to 138 percent of the federal poverty line gained coverage and increased access to care in states that expanded Medicaid under the Affordable Care Act (ACA), improving their physical and financial health. But recently, several states (Arkansas, Massachusetts, and Utah) have proposed using Medicaid’s section 1115 demonstration, or “waiver” authority, to limit eligibility for adults to 100 percent of the poverty line — sharply reducing the number of people who would be covered by expanded Medicaid. The Trump Administration has reportedly decided to reject these proposals, at least until after November’s midterm elections, but left the door open to future proposals.[1] While made for the wrong reasons — opposition to any expansion of Medicaid — its decision to reject partial expansions (at least for now) is the right one. Partial Medicaid expansion falls well short of full Medicaid expansion with respect to coverage and access to care. And allowing it would likely lead some existing expansion states to shrink their expansions and some states that would otherwise implement full expansions to adopt partial expansions instead.

The ACA gave states the option to expand Medicaid to low-income adults at an enhanced federal matching rate: the federal government covers 90 percent or more of the cost, compared to regular match rates which range from 50 to 76 percent. Currently, states wanting to take advantage of the enhanced match must cover the full expansion population and provide them with a comprehensive benefits package. In states that do not expand Medicaid, adults with incomes above 100 percent of the poverty line can enroll in subsidized coverage through the ACA marketplaces, while many of those with incomes below 100 percent of the poverty line fall into a “coverage gap,” ineligible for both Medicaid and marketplace subsidies.

Allowing partial expansion is likely to result in higher uninsured rates and worse access to care for near-poor adults.While partial expansion proposals address this coverage gap, allowing partial expansion is likely to result in higher uninsured rates and worse access to care for near-poor adults. That’s because letting states expand Medicaid just to those with incomes below 100 percent of the poverty line, with near-poor adults remaining in the marketplace, would create a strong financial incentive for states to roll back their existing expansions or expand Medicaid only to people below the poverty line. States pay a small share (10 percent or less) of the cost of covering near-poor adults through Medicaid, but none of the cost of covering them through the marketplace.

And replacing full expansions with partial expansions could lead to a significant loss of coverage and deterioration in access to care. While near-poor adults with incomes between 100 and 138 percent of poverty would have access to commercial coverage available through the marketplace, Medicaid coverage better meets their needs. It offers significantly lower premiums and cost sharing, coverage of non-emergency medical transportation (an important benefit for near-poor adults who often face transportation barriers), and the option to enroll at any time during the year, versus only during open enrollment. Due at least partly to these factors, uninsured rates are lower among near-poor adults in expansion than non-expansion states. Meanwhile, per-enrollee costs are lower in Medicaid than commercial coverage, making full expansion the more cost-effective approach to covering this group.

The partial expansion approach reportedly under consideration by Trump Administration officials raises even more serious concerns. Officials who support allowing partial expansion are reportedly seeking to structure the option as a “block grant,” similar to what was proposed in ACA repeal legislation introduced last year by Senators Bill Cassidy, Lindsey Graham, Ron Johnson, and Dean Heller.[2] Such a partial expansion approach would not only let states exclude near-poor adults from Medicaid, it would also likely let them restrict benefits and increase premiums and cost sharing to unaffordable levels. It would likely also mean approving Utah’s proposal to cap enrollment based on available state funding, an unprecedented restriction that would result in Medicaid-eligible individuals not being able to enroll once enrollment reaches the cap. Limiting and restricting coverage for low-income adults whom Congress intended to be covered under Medicaid doesn’t further the objectives of the Medicaid program, the legal standard for Medicaid waivers.[3]

Medicaid Expansion Has Improved Access to Care, Health, and Financial Security

The ACA’s coverage expansions, and Medicaid expansion in particular, have significantly increased coverage and improved access to care. States that have taken up Medicaid expansion have seen larger declines in their uninsured rates compared to non-expansion states. Medicaid expansion has also resulted in increased coverage for children as parents have gained coverage.[4]

These coverage gains have resulted in improved access to care. Medicaid expansion increased the share of low-income adults with a personal physician, getting check-ups, and getting recommended preventive care such as cholesterol and cancer screenings, and it decreased the share delaying care due to costs, skipping medications due to costs, or relying on the emergency room for care, among other improvements, studies have found.[5] Improvements have been especially important for people with chronic conditions; for example, studies have shown that Medicaid expansion was associated with improved glucose monitoring for beneficiaries with diabetes and better hypertension control.[6] Other health benefits associated with Medicaid expansion include lower rates of self-reported psychological distress, fewer days of poor mental health, and improved general health, according to a recent comprehensive review of the evidence.[7]

In addition to improving access to care and health outcomes for Medicaid beneficiaries, expanding coverage also has increased financial security by lowering medical debt and reducing the risk of medical bankruptcy. Expanding Medicaid coverage results in people having fewer and smaller unpaid medical bills and fewer debts sent to third-party collection agencies, studies have found.[8] In the expansion states of Arkansas and Kentucky, the share of low-income adults having trouble paying their medical bills dropped substantially, compared to low-income adults in the non-expansion state of Texas.[9] Moreover, with fewer and lower unpaid medical bills, adults who gained coverage through the Medicaid expansion have been found to have better credit, qualifying them for lower-interest mortgages and auto and credit card loans — leading to estimated savings that average $280 per adult gaining coverage per year on interest payments, and an estimated $520 million across the expansion population.[10]

Partial Expansion Proposals Would Restrict Coverage

Following the Supreme Court’s June 2012 decision in National Federation of Independent Business (NFIB) v. Sebelius finding that states could choose whether to take up the ACA’s Medicaid expansion, the Centers for Medicare & Medicaid Services (CMS) issued guidance in December of that year stating that while it would consider approving partial expansion proposals, the enhanced Medicaid expansion matching rate of 90 percent or more would only be available for full expansions.[11]

Wisconsin is the only state that has implemented a partial Medicaid expansion, providing Medicaid coverage to adults with incomes up to 100 percent of the poverty line through a waiver. In addition to limiting eligibility, Wisconsin’s waiver doesn’t provide all the benefits that would be covered under full expansion. Wisconsin receives its regular match rate of 58.5 percent for covering these adults, rather than the enhanced matching rate available to states implementing the full expansion.[12]

Recently, Arkansas and Massachusetts proposed amending their existing Medicaid waivers to lower Medicaid expansion eligibility from 138 to 100 percent of the poverty line — while maintaining the enhanced federal matching rate.[13] Earlier this year, CMS informed both Arkansas and Massachusetts that it is “not at this time” approving either state’s proposal.[14]

Then, in June 2018 Utah submitted an amendment to its existing section 1115 waiver that would extend Medicaid eligibility to additional low-income adults, but only those with incomes up to 100 percent of poverty. The proposal would also further restrict coverage by taking Medicaid away from individuals not meeting a work requirement, and capping enrollment if the Medicaid agency “has insufficient funding to provide services.”[15] Moreover, under the state law authorizing the partial expansion proposal Utah’s proposal would take effect only if CMS provides the enhanced Medicaid matching rate of 90 percent for the partial expansion. As noted above, the Administration has reportedly decided not to approve partial expansion waivers, at least in the near term.

Utah submitted its partial expansion proposal after enough signatures were obtained to allow Utahans to vote this fall on a ballot initiative to enact a full expansion of Medicaid. For a comparison of the state’s waiver proposal and the ballot initiative, see the textbox below.

Key Differences in Utah Medicaid Expansion Proposals

Medicaid expansion in Utah is at a crossroads. In November, Utah voters will consider a ballot measure proposing a full expansion of Medicaid to low-income adults up to 138 percent of the poverty line. Shortly after the initiative was approved for the ballot, the state enacted a partial expansion proposal.

As the table below shows, there are a number of major differences between the two approaches.

Perhaps most important, full expansion is indisputably permitted under federal law, does not require special waivers from the Centers for Medicare & Medicaid Services (CMS), and would qualify Utah for the enhanced federal match rate of 90 percent (and a higher match rate through 2019). In contrast, partial expansion might never take effect: the legislation allows it only if CMS grants a waiver allowing Utah to adopt a partial expansion while still receiving the enhanced match. Both Obama and Trump Administration policy has been not to grant such waivers, and the Trump Administration has reportedly decided not to revisit that policy in reviewing Utah’s waiver, at least in the near term.

Full expansion would also do significantly more to expand coverage and access to care in Utah than the partial expansion proposal, even if the latter were implemented. As discussed in the main text, full expansion offers more comprehensive and affordable coverage to near-poor adults and is likely to generate higher take-up (and therefore lower uninsured rates) among this group as a result. Moreover, Utah’s partial expansion proposal would take Medicaid coverage away from people not meeting work requirements and would impose enrollment caps based on state budget conditions. That means that Utah would likely still have a coverage gap: some people below 100 percent of the poverty line and meeting other eligibility requirements could find themselves stuck on waiting lists and unable to get coverage. In contrast, the full expansion ballot initiative prohibits the use of enrollment caps or more restrictive eligibility requirements than what was in place on January 1, 2017.a

  Partial Expansion Full Expansiona
Eligibility Level 100% Federal poverty line 138% Federal poverty line
Number of People Covered Through Medicaid 70,000 – 90,000 150,000
Work Requirements Yes No
Enrollment Caps Yes No
Enhanced Medicaid Match Rate Requested, but no such proposal has been approved to date Guaranteed
Requires CMS waiver approval to implement Yes No

Partial Expansion Proposals Fall Short on Affordable and Comprehensive Coverage

Partial expansion proposals fall short of full Medicaid expansion with respect to coverage and access to care for near-poor uninsured adults.

Medicaid Coverage Better Meets the Needs of Near-Poor Adults

The ACA marketplaces have expanded coverage to millions of low- and moderate-income people, but Medicaid provides coverage that better meets the needs of people with incomes just above the poverty line — part of why the ACA was designed to cover this group through Medicaid. Compared to marketplace coverage, Medicaid offers:

  • Lower premiums. Medicaid generally doesn’t impose premiums on beneficiaries with incomes below 150 percent of the poverty line.[16] Under partial expansion proposals, however, near-poor adults would be required to pay monthly premiums of 2 percent of income for “benchmark” coverage through the ACA marketplaces. As Table 1 shows, an adult with income at the poverty line usually wouldn’t have to pay any premiums for Medicaid coverage, but could be required to pay 2 percent, or $243 annually in 2018, for the benchmark marketplace plan. Research has found that even modest premiums significantly reduce coverage among low-income individuals.[17]
  • Lower out-of-pocket costs. Medicaid also has stronger protections on out-of-pocket costs than commercial coverage through the marketplace. Co-pays are generally set at nominal levels, and out-of-pocket spending on premiums and co-pays is capped at 5 percent of an individual’s quarterly or monthly income, or about $600 per year for a person at the poverty line.[18] While marketplace plans offer cost-sharing assistance to low-income individuals, these individuals would still face significantly higher out-of-pocket costs than in Medicaid, making it more difficult to afford going to the doctor or filling a prescription. A wide range of studies have found that even relatively small levels of cost-sharing on Medicaid beneficiaries, ranging from $1 to $5, are associated with reduced use of care, including necessary services.[19]
  • Access to coverage for people with costly employer plans. People who have an offer of employer-sponsored coverage are still able to enroll in Medicaid if they are otherwise eligible; in contrast, an employer offer disqualifies a person from claiming a premium tax credit for marketplace coverage if the employer offer is deemed “affordable.” The standard used to determine affordability — whether the lowest-cost plan costs less than 9.56 percent of household income — would put coverage out of reach for many near-poor workers. For example, a worker with income at the poverty line ($1,012 a month for a single individual in 2018) is barred from receiving marketplace financial assistance if offered a plan unless the premiums exceed about $100 per month. Such individuals either have to enroll in employer coverage with premiums that may be much higher than they would be expected to pay in the marketplace — or else go uninsured. Moreover, even if they managed to pay the premium for employer coverage, they would likely still face deductibles and other cost sharing well above what is allowable in Medicaid.
  • Additional benefits that ensure access to care and treatment. Medicaid provides additional and important benefits to near-poor adults that aren’t available in marketplace or employer plans. For example, Medicaid covers non-emergency medical transportation to ensure that lack of transportation doesn’t prevent near-poor adults from getting to the doctor. This is an important benefit for near-poor adults, as 3.6 million people miss or delay medical care each year because they lack available or affordable transportation.[20]

    Medicaid also provides additional benefits that help 19- and 20-year-olds successfully transition into young adulthood by ensuring access to the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. Medicaid’s EPSDT benefit guarantees access to a robust set of comprehensive and preventive health services, including regular well-child exams; hearing, vision, and dental screenings; and other services to treat physical, mental, and developmental illnesses and disabilities, such as speech and physical therapy and medical equipment and supplies. Medicaid eligibility as a child ends at 19 years of age, but 19- and 20-year-olds enrolled through expansion are still entitled to this important benefit.

  • More opportunities to enroll in coverage. Another important feature of Medicaid is that near-poor adults can enroll at any point during the year rather than during the time-limited open enrollment period for commercial coverage through the marketplace. For near-poor adults with complex medical and financial circumstances, signing up for coverage during a time-limited period may not be realistic. Medicaid ensures that these individuals don’t lose out on coverage by allowing them to enroll at any point during the year.
TABLE 1
Coverage Options for a Single Adult With Income at the Poverty Line, 2018
  Medicaid in Expansion States ACA Marketplace in Non-Expansion States
Typical Premiums $0 $20/month
Typical Deductibles $0 $234a
Out-of-Pocket Spending Limit $600 ($50/month or $152/quarter) $970b
Benefits Covered Essential health benefits + non-emergency medical transportation and EPSDTc Essential health benefits
Availability of Coverage When needed Open enrollment, or if people lose coverage or have a major life change
Impact of Employer Coverage Qualification based on income, regardless of an employer offer Subsidy available unless individual has an affordable employer offer

a Kaiser Family Foundation, “Cost-Sharing for Plans Offered in the Federal Marketplace for 2018,” November 3, 2017, https://www.kff.org/health-reform/fact-sheet/cost-sharing-for-plans-offered-in-the-federal-marketplace-for-2018/.

This annual amount is based on a silver plan offered in the marketplace that has an actuarial value of 94 percent, which would be available to an adult with income at 100 percent of poverty.

bIbid.

c The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit is only available for 19- and 20-year-olds.

Fewer People Will Be Covered and Experience Benefits of Expansion

Likely in large part because of the differences described above, uninsured rates among people with incomes between 100 and 138 percent of the poverty line are significantly higher in non-expansion states — where they can enroll in subsidized coverage through the marketplaces — than in expansion states — where they can enroll in Medicaid. Treasury Department data show that 37 percent of adults with incomes between 100 and 138 percent of poverty who live in non-expansion states were uninsured in 2014, compared to 25 percent of such adults in expansion states.[21] This suggests that limited expansion is likely to result in lower coverage among this group than full expansion.

Similarly, when states lowered Medicaid eligibility for adults after marketplace coverage became available, the result has been fewer people covered. Connecticut and Rhode Island lowered eligibility for parents with incomes over the eligibility limit for Medicaid expansion (i.e., over 138 percent of the poverty line), while Wisconsin lowered eligibility for adults whom the state had covered under its pre-ACA Medicaid waiver. These states assumed that people would move out of Medicaid into marketplace coverage, but large numbers did not make the transition. In Connecticut, during the first round of a rollback in parent eligibility, only 1 in 4 parents losing Medicaid coverage enrolled in a qualified health plan (QHP).[22] In Wisconsin, only one-third of those losing Medicaid coverage in 2014 purchased QHPs, although the state had predicted that 90 percent would.[23] And in Rhode Island, despite considerable efforts at outreach to enroll parents losing Medicaid, 1,271 of the 6,574 people who lost Medicaid — or 19 percent of them — did not subsequently apply to enroll in a QHP in the marketplace, and many likely became uninsured.[24] While participation rates may have improved since the initial transition, they’re likely to still be lower than they were in Medicaid.

Medicaid Expansion Makes the Marketplace Work Better

Studies show that marketplace premiums are lower in states that expanded Medicaid and that expansion states, on average, have healthier individual market risk pools.a

Medicaid expansion affects marketplace premiums because it affects who’s in the marketplace risk pool. In non-expansion states, adults with incomes between 100 and 138 percent of the poverty line, who are eligible for subsidies to purchase marketplace coverage, make up an estimated 40 percent of the marketplace population.bLower-income individuals tend to be in worse health than those with higher incomes, which means they’re often sicker and have higher health care costs. Almost 20 percent of people with incomes between 100 and 138 percent of the poverty line report being in fair or poor health compared to about 8 percent of people with incomes above 138 percent of the poverty line.c

Moreover, there’s probably some adverse selection in which near-poor individuals sign up for marketplace coverage. Even with subsidies, marketplace premiums strain near-poor workers’ budgets, which is part of why the ACA envisioned this group getting coverage through Medicaid. Although a large share of marketplace enrollees in non-expansion states are in this income group, the people who most need health coverage are most likely to sign up for it, making an already sicker-than-average population even sicker.

 

aAditi P. Sen and Thomas DeLeire, “The Effect of Medicaid Expansion on Marketplace Premiums,” Assistant Secretary for Planning and Evaluation, Department of Health and Human Services, September 6, 2016, https://aspe.hhs.gov/system/files/pdf/206761/McaidExpMktplPrem.pdf, and Ashley Semanskee, Cynthia Cox, and Larry Levitt, “Data Note: Effect of State Decisions on State Risk Pools,” Kaiser Family Foundation, October 2016, http://files.kff.org/attachment/Data-Note-Effect-of-State-Decisions-on-State-Risk-Pools.

bIbid.

cIbid.

Spending More to Achieve Less

A key problem with approving partial expansion proposals at enhanced match is that doing so would create a strong financial incentive for states to roll back their existing expansions or expand Medicaid only to people below the poverty line, even if they would otherwise adopt expansion in full. That’s because states pay a small share (10 percent or less) of the cost of covering near-poor adults through Medicaid, but none of the cost of covering them through the marketplace.

If states did roll back their expansions, the federal government could end up spending more to achieve less improvement in coverage and access to care. As discussed above, partial expansions would result in higher uninsured rates and worse coverage for people with incomes between 100 and 138 percent of the poverty line. And because commercial coverage costs more than Medicaid,[25] total federal and state costs per person covered would be higher under partial expansion than full expansion. Because of these higher per-person costs, and because the federal government would bear all of, rather than the large majority of, that cost, it could well end up spending more in total to cover fewer people and offer them worse coverage.

Reported Administration Proposal Highlights Additional Risks of Partial Expansion

As discussed above, the Administration reportedly considered and rejected approving Utah’s partial expansion proposal, although it may re-open the question after the November election. The Administration reached the right decision for the wrong reasons, reportedly because it did not want to affirmatively endorse expansion in any form.

The specific partial expansion approach the Administration reportedly considered, however, highlights additional dangers associated with partial expansion, on top of those discussed above. Apparently, some members of the Administration argued for approving partial expansion, but under a block grant approach in which states would receive a fixed federal allotment to cover some additional low-income adults, rather than flexible federal funding based on the demand for and cost of coverage. Under such an approach, Utah would also likely be allowed to implement its proposed enrollment cap, meaning that low-income adults might or might not be able to obtain coverage, depending on the extent of state and federal funding. That would be an unprecedented departure from Medicaid’s current treatment of expansion and non-expansion populations alike, since Utah would not be required to guarantee coverage to eligible people. Such a departure could result in significantly worse outcomes for low-income adults than under other, already damaging proposals to simply reduce income limits for expansion.

Conclusion

Partial expansion proposals may expand coverage to some low-income adults in non-expansion states, but they would cause a significant loss of coverage if approved in expansion states. Moreover, partial Medicaid expansions would provide near-poor adults with less affordable and comprehensive coverage. With fewer people covered, partial expansion would achieve smaller improvements in access to care and physical and financial health than full Medicaid expansion. Limiting coverage and access to care doesn’t further the objectives of Medicaid, making such proposals inappropriate for section 1115 waiver authority.

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End Notes

[1] Robert Pear, “Trump Spurns Medicaid Proposal After Furious White House Debate,” New York Times, July 30, 2018, https://www.nytimes.com/2018/07/30/us/politics/trump-medicaid-partial-expansion.html.

[2]Ibid. For more information on Graham-Cassidy, see Center on Budget and Policy Priorities, “Roundup: CBPP Analyses of Cassidy-Graham Proposal,” September 22, 2017, https://www.cbpp.org/blog/roundup-cbpp-analyses-of-cassidy-graham-proposal.

[3] Section 1115 of the Social Security Act provides broad, but not unlimited, authority to deviate from certain provisions of Medicaid law. It also authorizes federal Medicaid funding for activities that, in the absence of a waiver, would not qualify for it (e.g., providing benefits that aren’t typically covered by Medicaid). For more information on section 1115 demonstration projects, see Judith Solomon and Jessica Schubel, “Medicaid Waivers Should Further Program Objectives, Not Impose Barriers to Coverage and Care,” Center on Budget and Policy Priorities, August 29, 2017, https://www.cbpp.org/research/health/medicaid-waivers-should-further-program-objectives-not-impose-barriers-to-coverage.

[4] Robin Rudowitz and Larisa Antonisse, “Implications of the ACA Medicaid Expansion: A Look at the Data and Evidence,” Kaiser Family Foundation, May 23, 2018, https://www.kff.org/medicaid/issue-brief/implications-of-the-aca-medicaid-expansion-a-look-at-the-data-and-evidence/.

[5] See Benjamin D. Sommers et al., “Changes in Utilization and Health Among Low-Income Adults After Medicaid Expansion or Expanded Private Insurance,” Journal of the American Medical Association, October 2016, http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2542420. For a review of the literature, see Assistant Secretary for Planning and Evaluation, “Medicaid Expansion Impacts on Insurance Coverage and Access to Care,” Department of Health and Human Services, updated January 18, 2017, https://aspe.hhs.gov/system/files/pdf/255516/medicaidexpansion.pdf.

[6] Olena Mazurenko et al., “The Effects of Medicaid Expansion Under the ACA: A Systematic Review,” Health Affairs, June 2018, https://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.2017.1491.

[7]Ibid.

[8] Matt Broaddus, “Study: Medicaid Expansion Improves Low-Income Peoples’ Financial Health, Too,” Center on Budget and Policy Priorities, November 14, 2017, https://www.cbpp.org/blog/study-medicaid-expansion-improves-low-income-peoples-financial-health-too, and Matt Broaddus, “Medicaid Improves Financial Well-Being, Research Finds,” Center on Budget and Policy Priorities, April 28, 2016, http://www.cbpp.org/blog/medicaid-improves-financial-well-being-research-finds.

[9] Benjamin Sommers et al., “Three-Year Impacts Of The Affordable Care Act: Improved Medical Care And Health Among Low-Income Adults,” Health Affairs, May 2017, http://content.healthaffairs.org/content/early/2017/05/15/hlthaff.2017.0293.

[10] Kenneth Brevoort, Daniel Grodzicki, and Martin Hackmann, “Medicaid and Financial Health,” National Bureau of Economic Research, November 2017, http://www.nber.org/papers/w24002.pdf.

[11] Centers for Medicare & Medicaid Services, “Frequently Asked Questions on Exchanges, Market Reforms and Medicaid,” December 10, 2012, https://www.medicaid.gov/federal-policy-guidance/downloads/FAQ-12-10-2012-Exchanges.pdf.

[12]Assistant Secretary for Planning and Evaluation, “Fiscal Year 2017 Federal Medical Assistance Percentages,” https://aspe.hhs.gov/basic-report/fy2017-federal-medical-assistance-percentages.

[13] While Arkansas’ Medicaid expansion, or “private option,” enrolls Medicaid beneficiaries into commercial coverage through the state’s marketplace, this coverage is subject to the same contribution requirement and beneficiary protections as a traditional Medicaid expansion. In particular, Arkansas pays the same share of costs as other expansion states and supplements marketplace coverage with additional benefits and cost-sharing protections to comply with Medicaid standards. For more information on Arkansas’ and Massachusetts’ waivers and limited expansion proposals, see Jessica Schubel, “Proposals to Lower Medicaid Expansion Eligibility Jeopardizes Coverage for Low-Income Adults,” December 19, 2017, https://www.cbpp.org/research/health/proposals-to-lower-medicaid-expansion-eligibility-jeopardize-coverage-for-low-income,.

[14] Centers for Medicare & Medicaid Services, “Approval letter to Arkansas,” March 5, 2018, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/ar-works-ca.pdf, and Centers for Medicare & Medicaid Services, “Approval letter to Massachusetts,” June 27, 2018, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ma/ma-masshealth-ca.pdf, and Pear.

[15] State of Utah, “Amendment to the State of Utah’s 1115 Primary Care Network Demonstration Waiver,” June 22, 2018, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ut/ut-primary-care-network-pa4.pdf.

[16] Some states have received section 1115 waivers to impose premiums on Medicaid beneficiaries with incomes as low as 50 percent of the poverty line. CMS has generally only allowed premiums up to 2 percent of annual income, consistent with the marketplace standards. However, it recently gave Kentucky unprecedented authority to impose premiums up to 4 percent of annual income. Even among states with premiums, only some take away coverage from people who fail to pay, and only Indiana and Kentucky lock beneficiaries out of coverage for a period for non-payment. (Kentucky’s waiver is currently on hold due to a federal court decision vacating CMS’s decision to approve it.)

For more information on states that impose premiums, see Marybeth Musumeci et al., “Section 1115 Medicaid Demonstration Waivers: The Current Landscape of Approved and Pending Waivers,” Kaiser Family Foundation, March 8, 2018, https://www.kff.org/medicaid/issue-brief/section-1115-medicaid-demonstration-waivers-the-current-landscape-of-approved-and-pending-waivers/, and Jessica Schubel, “Kentucky’s Medicaid Waiver Gives State Unprecedented Power to Raise Premiums, Impose Fines,” March 5, 2018, https://www.cbpp.org/blog/kentuckys-medicaid-waiver-gives-state-unprecedented-power-to-raise-premiums-impose-fines.

[17] Samantha Artiga, Petry Ubri, and Julia Zur, “The Effects of Premiums and Cost-Sharing on Low-Income Populations: Updated Review of Research Findings,” Kaiser Family Foundation, June 1, 2017, https://www.kff.org/report-section/the-effects-of-premiums-and-cost-sharing-on-low-income-populations-updated-review-of-research-findings-table-2/.

[18] In states that impose premiums, premiums are included in calculating the 5 percent out-of-pocket spending cap.

[19] Artiga, Ubri, and Zur.

[20] MaryBeth Musumeci and Robin Rudowitz, “Medicaid Non-Emergency Medical Transportation: Overview and Key Issues in Medicaid Expansion Waivers,” Kaiser Family Foundation, February 24, 2016, https://www.kff.org/medicaid/issue-brief/medicaid-non-emergency-medical-transportation-overview-and-key-issues-in-medicaid-expansion-waivers/.

[21] Ithai Z. Lurie and Janet McCubbin, “What Can Tax Data Tell Us About the Uninsured? Evidence from 2014,” U.S. Department of Treasury, Office of Tax Analysis, July 2016, https://www.treasury.gov/resource-center/tax-policy/tax-analysis/Documents/WP-106.pdf.

[22] Sharon Langer, Mary Alice Lee, and Dumingu Aparna Gomes, “Husky Program Coverage for Parents: Most Families Will Feel the Full Impact of Income Eligibility Cut Later in 2016,” Connecticut Voices for Children, April 2016, http://www.ctvoices.org/sites/default/files/h16HUSKYIncomeEligibilityCut.pdf.

[23] Guy Boulton, “One-third who lost BadgerCare coverage bought plans on federal marketplace,” Journal Sentinel, July 16, 2014, http://archive.jsonline.com/business/almost-19000-badgercare-plus-recipients-enrolled-in-obamacare-b99312352z1-267339331.html.

[24] Kate Lewandowski, “Parent Eligibility Roll-Back in Rhode Island: Causes, Effects and Lessons Learned,” Community Catalyst, September 2015, https://www.communitycatalyst.org/resources/publications/document/RI-parent-rollback-081215-KL.pdf?1439834245.

[25] Lisa Clemans-Cope, John Holahan, and Rachel Garfield, “Medicaid Spending Growth Compares to Other Payers: A Look at the Evidence,” Kaiser Family Foundation, April 13, 2016, https://www.kff.org/report-section/medicaid-spending-growth-compared-to-other-payers-issue-brief/.