Causes and Effects of the Affordable Care Act

Abstract

With the implementation of the Affordable Care Act, the aim was to provide affordable coverage to all Americans by offering costly incentives. There were unforeseen circumstances in its inception. Premiums were unaffordable. States refused to expand of public health programs to include a low cost option of insurance. A detailed analysis of regulatory and budgetary concerns under the public health expansion provisions under this legislation may cost the federal government and states in the long run.

Introduction

For decades, securing health insurance coverage is a task that Americans must bear. The United States (US) is one of a few countries which does not provide health care to its citizens at no cost. As a result, Americans are expected to bear the financial responsibility of health care costs which have the potential to bankrupt individuals and families, especially in the event of a catastrophic medical occurrence. Having access to affordable health care in the United States is a topic that concerns many Americans because ensuring the accessibility and affordability of health insurance coverage seemingly never comes to a resolution. 

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Many
Americans derive health insurance coverage through an employer-based program
which is works well for the employee. These type policies usually have low cost
or no premiums and/or low deductibles or co-payments. However, when dependents
are added, the costs associated with coverage for the employee and their
dependents skyrocket, making health care unaffordable. Consequently, many
Americans are left without insurance benefits. In fact, there are approximately
28.2 million persons under age 65 who are uninsured (cdc.gov/nchs/fastats/health-insurance.htm)[1]. To
mitigate the rates of individuals who lack health insurance coverage, the
Affordable Care Act (ACA or Obamacare) was enacted.

In
addition to providing assistance with the costs associated with private
insurance coverage, Obamacare also included provisions to expand public health
programs, such as Medicaid and made enhancements to the Children’s Health
Insurance Program (CHIP) to assist Americans with expenditures related to
health care. Although this public policy’s focus was to relax the eligibility
requirements and make being insured easier and more affordable, the states
still have the discretion on how these programs are implemented. As a result,
many states exercised the option to not expand provisions to include
individuals who traditionally would not meet the strict income eligibility
guidelines of these public health programs; therefore, Americans still find
accessibility to care difficult and the costs still unaffordable.

Statement
of Purpose

The
intent of ACA was to ensure that Americans received access to affordable health
care coverage and services. As previously stated, this legislation included
provisions to make public health programs more accessible to individuals who
would otherwise not meet the strict income eligibility guidelines. In order to
accomplish this, ACA provided the states with the option to expand these
programs. It was the hope of the authors of this public health policy that
expanding these public health insurance programs would significantly decrease
the number of uninsured Americans and improve overall health outcomes. However,
unforeseen circumstances emerged. A vast majority of states rejected Medicaid
and CHIP expansion, leaving a high percentage of Americans without insurance
coverage. Therefore, the problem remains; the accessibility to affordable
health care is not a realization for many Americans-even after the
implementation of ACA.

The
purpose of this paper is to review public health programs and how they were
implemented prior to ACA and the funding sources for these programs during that
time period. Also, after the effectuation of the Affordable Care Act, changes
to public health programs were implemented as well as source funding. A review
of ACA policies regarding Medicaid and CHIP will be conducted to determine the
cost effectiveness of how these programs run since its enactment and the costs
associated with expanding these public health programs to be inclusive of a
broader population of Americans to decrease the amount of individuals who lack
health insurance coverage. The scope of the research will provide an analysis
of the regulatory and regulatory constraints of Medicaid and CHIP programs and
provide a comparative analysis of these programs to other health care systems
outside the United States to ascertain the benefits of making health care
accessible and affordable to those uninsured populations.

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 Overview

The
Medicaid program was designed to assist families with dependent children during
the Great Depression. Billed as a component of the Social Security Act, this
public health program was tied into the financial need of families during this
era. The federal government provided states with funding to assist families
with household and any medical expenses the family incurred. The entire
financial and health care package was known as Aid to Families with Dependent
Children (AFDC). The AFDC program was successful in that it provided medical
benefits to low-income families of that time period. The provisions were
amended giving states the regulatory support to change the way the program was
applied. The cash assistance portion of AFDC continued to assist with household
expenses but medical payments were now authorized to be sent directly to the
provider in an effort to control costs.

For decades, the AFDC program operated as a contingency program, where AFDC payments were accompanied by Medicaid coverage. The federal government provided the financial support to the states for Medicaid coverage. States were required to match federal dollars, but the federal government covered approximately 57% of program costs (Mann, Rowland, Garfield, (2007)[2]. As a result, the states were able to govern the program as it saw fit. The states made the rules regarding financial eligibility standards. Most families who qualified for this program were mainly single-parent families who had little-to-no income.

The
Social Security Act was once again amended to transition the Medicaid program
from its linkage to AFDC. Delinking Medicaid expanded coverage to include
families and children who were not financially dependent upon the cash portion
of AFDC. As a result, the number of children and families enrolled in Medicaid
significantly increased. Although the federal government bore the majority of
program costs, the states began to experience significant increases in program
costs. Once the states began to feel the budgetary effects of the increased
costs to insure low-income children and families, the states needed a new
methodology to continue to provide medical care at lower costs. Therefore,
states moved to managed care health care model to help curb costs. As a result,
enrollment in Medicaid managed care began to increase but costs associated with
care were contained. Medicaid became the largest insurer of children in the
United States, and, as a result, impacted the health status of its
beneficiaries through managed care.

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After the implementation of public policy reforming welfare in 1996, the federal government encouraged states to expand Medicaid coverage to reach those children and families who were slightly above the Federal Poverty Level (FPL). Many states were reluctant; however, coverage was inevitably increased to reach these children who were not “poor enough”, hence, the birth of CHIP.

In
its initial stages, states that chose to provide coverage to children through
CHIP received an additional $40 billion in federal assistance over a ten-year
period (Mann et al, 2007)[3]. However,
these funds are limited. The federal government provides block grants as a
funding source for CHIP. Although the states are not responsible for the
complete cost associated with CHIP, the block funds are not nearly enough to
insure these children whose family income is slightly over the poverty level. Therefore,
to control costs, the states decided to place strict limitations on care. To
cover the short-fall families are assigned monthly premiums in addition to
having co-payments for physician visits and medications. Also, when funds
recede, there are enrollment freezes resulting in waiting lists which may last
for several months, and even years. 

      Table 1 [4]

The
Affordable Care Act is funded through taxes collected as well as penalties
imposed on those individuals who are not in compliance with obtaining mandatory
health coverage. A portion of these monies are used as a source of grant
funding for states to expand Medicaid-providing access to health care to
individuals who otherwise cannot afford coverage. The intent of this policy is
to fill gaps in health care coverage for lower income Americans. Thus,
incentives for states to expand Medicaid is for the federal government to offer
100% financing for all adults newly added to the Medicaid program for the first
three years; thereafter, financing would be scaled down to 90% (CMS.gov)[5].  

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A
provision within health insurance coverage, as a requirement of the Affordable
Care Act, mandated insurers to provide access to preventative care to head off
illnesses prior to onset by helping individuals to remain healthy. Additionally,
access to primary health care services is the mechanism by which chronic
diseases are managed in order to control the costs of treatment for these type
illnesses which have the potential to become more difficult to control and
drive up costs of care. In order to remain true to its intent of preventative
care, all insurers are required to cover 100% of the cost of preventative care
services as well as annual visits which include well women examinations as well
as the cost of contraception.

The
Affordable Care Act provides access to distinct amenities that are now
available to consumers that were not viable options prior to the implementation
of the law. The accessibility of these amenities now extends to include the
following:

• Individuals can no longer
  be denied coverage for preexisting conditions.
• The cost of coverage is
  contained at a rate that is the same for everyone, regardless of health status
  or gender.
• Women’s health services
  are covered. This includes preventative treatments and screenings which are at
  no cost.
• There are more
  protections available to senior citizens where there is more access to
  services.
• Out of pocket limits no
  longer exist for emergency room visits, medications, as well as maternity and
  neonatal care, to name a few.
• Referrals are no longer
  required for obstetrical and gynecological services.

Moreover, there are ten essential
benefits that insurers (including public health programs) must provide without
lifetime limits (“Obamacare Facts”)[6].

• Emergency services
• Hospitalizations
• Laboratory services
• Maternity care
• Outpatient or ambulatory
  Care
• Pediatric care
• Preventative care
• Vision and dental care
  for children
• Prescriptions
• Mental Health and
  substance abuse services

Although
the Affordable Care Act provides accessibility to coverage for many Americans,
there are minor changes to the structure of accessibility. There continues to
be multiple insurers (including Medicaid and CHIP) which must provide the
aforementioned coverage. As a result, the Affordable Care Act has not done much
to change the structure to the health care system in insuring Americans have
coverage. The onus to have coverage remains with Americans. Americans have
access to broader coverage options; however, care continues to be heavily
dependent cost sharing. While many Americans continue to derive health
insurance through their employer, that population of individuals who purchase
coverage through the exchange will experience pricing of premiums and deductibles
based on age, the quality of health he or she has and which tier he or she
selects which may limit the individual’s access to much needed services because
of costs as well as fewer covered services (see table 2). This makes
accessibility to coverage somewhat limited because monthly premiums are high
with extremely high deductibles and drug costs. More importantly, ACA does
little to address the challenges of controlling costs of coverage and ensuring all
Americans have access to affordable care.

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Table 2 illustrates the
tier system under the Affordable Care Act[7]

In
the early stages of implementation, the Affordable Care Act provided funds to
non-profit cooperative plans. These plans received $2.5 billion in grants. The
intent of the cooperative plans was to displace for-profit insurers. However,
these plans failed to deliver the intended results. Many of these plans
provided coverage that was grossly underpriced. As a result, of twenty-three
cooperative plans, all but five are no longer in existence. Six cooperative
plans received $3.56 million in emergency funding to continue to operate
(Gottlieb 2[8]).

The Affordable Care Act poured funds into preventative health care. The Prevention and Public Health Fund has an appropriation of approximately $2 billion annually to invest in a host of wellness programs.

Obamacare
funneled money into incentives for private insurers to offer coverage to
Americans at affordable rates as well as provided funding for expansion of
Medicaid and CHIP. But, private insurers resisted by merging in an effort of
pooling resources to provide the mandated coverage. This did little to nothing
to drive down costs. It had the adverse effect. It drove smaller insurers to
bankruptcy. And, states refused the incentives offered by the federal
government for providing Medicaid and CHIP to a broader group of citizens who
are uninsured. Additionally, states still controlled how Medicaid and CHIP were
implemented. Thus, there are varying degrees of coverage by state for the two
public health programs. This makes Medicaid and CHIP programs non-transferable.
In other words, if children and families who are covered by Medicaid or CHIP
experience a medical emergency while on vacation in another state and need to
be seen by a physician, that visit will not be paid by Medicaid.   

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In
contrast, Canada has universal health care that is accessible to all of its
citizens. All Canadian citizens, regardless of age, employment, or the ability
or inability to pay are insured. Canada’s primary focus is to provide its
citizens with access to preventative medicine and unrestricted access to
primary care services as well as hospital services at no cost to the
individual.   

The
Canadian Health Act directs provinces and territories to provide individuals
with unrestricted access to health care. The provinces also mandated to fund
health care services for its residents.

In
Canada, coverage is universal in that all who are insured are to receive the
same type coverage and health services. Moreover, Canada’s universal system is
portable. Portability ensures that an individual continues to have coverage
regardless of moving to another province or territory. He or she will remain
covered. There are some provinces within the Canadian system which may require
an individual to pay health care premiums for services. Although this may be
the case, health care services cannot be denied because an individual may not
be able to pay for services. Additionally, provinces are not required to
provide services which are outside the scope of the Canadian Health Act
meaning, provinces and territories are merely required to provide basic health
care coverage for basic services.

Under
Canada’s universal health care package, vision, dental, and prescription
medications are excluded. Canadians have the option to utilize private insurance
to cover these services. Private insurance makes vision, dental, and
prescription medications accessible in a health care system that is not
required to provide these services. Many Canadian’s are offered this coverage
as a benefits package by employers. Furthermore, this type of insurance is also
available for purchase from private providers. However, the vast majority of
Canadian’s elect to receive services under the national health plan offered at
no cost.

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In
order for an individual to receive the universal coverage offered by provinces,
an application must be completed and submitted to the province. Once the
individual is registered, he or she receives a health card. This card must be
presented in order to receive services. There are no “managed care”
restrictions in Canada’s universal health system. An individual can show up to
any clinic in their area and present their medical card and receive care.

Although
Canadians do not have any cost sharing expenses when they incur medical
expenses, the universal health coverage they receive has associated costs. Canada’s
universal health plan has a variety of funding sources. Unlike Obamacare, it is
difficult to discern the amount of tax dollars dedicated to this public program
as there is no line-item specifically for health insurance tax. Canada finances
health coverage for its citizens though:

• Income tax dollars
• Employment insurance
• Pension premiums
• Land taxes
• Alcohol and tobacco tax
• Imports

Approximately $141
billion of tax revenues were allocated to universal health care which equates
to about $3,961 per Canadian, which is an equal share representation (Palacios,
Barua, and Ren, 2015)[9]. 

Table 3[10]

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For well over 40 years, Canada
has carried out a universal health care program under a single-payer system. The
provisions Obamacare implemented, such as preventative care services and
coverage being provided regardless of any pre-existing conditions mirror the
Canadian model. But, Canadians are able to achieve universal health care at
cheaper costs. According to the Congressional Budget Office, the United States
spends approximately more than $300 billion in Medicaid and CHIP insurance
programs and close to $300 billion for work related coverage; these figures are
applicable to subsidies only and is only representative of people under 65. In
whole, the United States spends about 18% of the gross domestic product (GDP) on
health care, which is up by about 6%. This translates to $3.2 trillion, or
close to $10,000 per American (CMS.gov/research-statistics). In contrast,
Canadians provided health care coverage to 100% of its citizens. This breaks
down to $242 billion or $6,604 per Canadian citizen and represents 11.4% of the
GDP.

Methodology

Medicaid is a combined program financed by federal and
implemented by state governments, which, in conjunction with the Children’s
Health Insurance Program, makes health coverage available to millions of Americans.
Medicaid is the principle resource of health coverage in the US. Federal law made
it a requirement for states to provide insurance coverage to a particular group
of individuals. Families with income below the poverty level, pregnant women and
children, and disabled individuals who receive Supplemental Security Income
(SSI) are examples of persons who are included in these mandatory
eligibility groups.

Table
4 illustrates the financial eligibility standards for Medicaid eligibility in
the state of Florida.[11]

 Obamacare legislation
gave states the opportunity to expand Medicaid to cover nearly all impoverished
Americans under the age of 65. It included a requirement that eligibility for
that had not expanded have the option to do so at any time.

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The ACA provisions also revised antiquated eligibility
methods and developed a new methodology for Medicaid eligibility
determinations. This method is based on the Modified Adjusted Gross Income
(MAGI) of low-income households. MAGI determines financial eligibility for
Medicaid and CHIP, as well as used to determine tax credits for coverage
premiums and reductions to cost sharing. This public health legislation
revolutionized conventional methodologies for applying income by utilizing a
new set of standardized rules. This substituted AFDC income calculation
methodologies which included income disregards which differed by state. Additionally,
MAGI eliminated all resource testing whereas individuals seeking Medicaid
coverage had to have resources no greater than $2,000.

Also,
ACA developed a streamlined application process for these programs making it a
more simplified process for people to apply and receive medical benefits in the
program for which they are eligible.

There are groups of individuals who are not included in the
MAGI-based income counting methodology. These groups include individuals whose
eligibility is contingent upon meeting the definition of disability due to blindness,
other disabling impairments, or age 65 and older. Medicaid eligibility for these
individuals is determined by using income methodologies based on Supplemental Security
Income (SSI) program which is overseen by the Social Security
Administration (SSA). Although this program is based upon established rules and
guidelines administered by the SSA, the states are still partially responsible
for costs related to insuring this population of Americans. Additionally,
Medicaid eligibility can include individuals who are insured under the Medicare
program because it provides assistance to individuals with Medicare premium
payments, payment of Medicare deductibles (for lower income disabled
individuals) and/or co-payments. This program is also based on SSI income methodologies.

There are Medicaid eligible groups who are exempt from
the process of income determination. The coverage for these individuals is based
on enrollment in another program under Medicaid entitlement. These programs
are:

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• SSI
• Breast
  and Cervical Cancer Treatment and Prevention Program
• Children of
  adoption who have an active adoption assistance agreement
• Young
  adults who “aged-out” of foster care are also eligible at any income level

Medicaid eligibility is based on other conditional
requirements. Individuals have non-financial eligibility standards they must
meet. The individual must be a resident of the state in which they receive Medicaid
coverage, be citizens of the US or meet specific requirements as a qualified
non-citizen, such as be a lawful permanent resident.

Once all eligibility requirements are met for Medicaid,
coverage begins on the first day of the month of application. Individuals may
also be eligible for retroactive Medicaid coverage for up to 3 months before
the application date. If the individual no longer meets Medicaid requirements,
coverage ends at the end of the month as the individual no longer meets the
eligibility requirements.

There is a “spin-off” Medicaid program called medically
needy which is for individuals who have major health needs and whose income is above
the Medicaid income eligibility standard. Medically needy individuals must
“spend down” the income that is exceeds their state’s medically needy income
standard (MNIL). This occurs as individuals incur expenses for medical and corrective
care. Once these medical expenses surpass the difference between the
individual’s income and the state’s medically needy income level (the “spend down”
amount), the person can be eligible for Medicaid (CMS.gov). Once eligibility is
derived, Medicaid pays the cost of services that exceed the incurred medical
expenditure.

Table
5

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In
looking at the Medicaid and CHIP programs holistically, the coverage options do
not differ much from that of Canada. But, Canada’s universal health care
program spends less in providing basic care to 100% of its Citizens. Additionally,
health outcomes are better than that of the US. Canadians have lower infant
mortality rates and the life expectancy is approximately 10 years that of the
United States.

Since
the ACA revised public health program requirements, directed astronomical
federal funding to states to get on board with public health care expansion,
and relaxed income and asset standards of eligibility for these programs to
streamline coverage and attempt to control costs, as well as to provide health
care to the uninsured.

Obamacare
did not reach far enough to achieve its goal; to provide health coverage to the
uninsured. Individuals are still grappling with the high costs of private
health care; the inability to provide coverage to their dependents through
employer based health insurance due to costs, and is still shut out by public
funded health care. Thus, the costs to implement this legislation and provide
mandated coverage remains futile, at best. Therefore, with the amount of
federal funds that went towards the cost of private health programs in making
Obamacare “work”, these funds may have been more beneficial in providing
universal health coverage to Americans billed under Medicaid and CHIP programs.

Analysis

The
main purpose of ACA is to decrease federal spending on health care.
Historically, public health programs spent over $676 billion, or 10.4% of the
federal budget (Amadeo, 2017). These costs are projected to double by the year
2020 and will be approximately 20% of the budget federal budget (Amadeo, 2017).
Medicaid and CHIP programs are part of a fixed spending package which
cannot be rolled-back without a congressional vote. 

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The state and federal governments are
responsible for funding Medicaid. Funding of Medicaid for adults is
matched at a much higher rate as a part of Medicaid expansion provisions under
ACA. Medicaid spending totaled $549.8 billion, with 10.5% allocated to newly Medicaid
eligible adults (CMS.gov). In prior
years, the federal government’s allocation to Medicaid was about 57% (as
previously stated). This included 100% of Medicaid costs fully funded by the
federal government for a specific newly eligible demographic. The allocated
funds began to slightly taper off each year until it reaches the targeted
threshold in 2020 and stays there. All Medicaid recipients received the 100%
match of federal dollars which included those who were not historically eligible
for Medicaid. The matching rate continually increased by a conversion factor
and by the year 2020 the all Medicaid and CHIP rates will have the same federal
matching rate as newly eligible adults.

The total cost spent
on Medicaid increased by 11.6%, which
translates to $549.8 billion. This is attributable to an increase in federal
spending, per Medicaid recipient, which rose by 16.0%, with 4% of growth
happening between the year 2014 and 2015 (CMS.gov).

The Centers for
Medicare & Medicaid Services (CMS) statistical report showed the average
cost for a newly Medicaid eligible adult was approximately $6,365. This amount
surpassed Medicaid spending for other non-disabled adults by about 12% per Medicaid
enrollee. In the year 2015, the estimated cost for newly eligible adults (per
enrollee) was approximately $5,926, which is a 7% decrease. This figure is still
about 14% greater, per enrollee, than for other non-disabled adults who receive
Medicaid.

These higher costs are
attributed to the monthly capitation rates paid to the managed care plans. Since
the newly eligible Medicaid adult population is limited, the states that chose
to expand Medicaid may have set the managed care rates for this group at a
higher level as a result of the uncertainty of the actual cost of health care services
at inception. Costs for newly eligible adults are expected to continue to
decrease to less than the costs of other non-disabled Medicaid eligible adults
by 2018 (CMS.gov).

Studies show that those
individuals who are potentially eligible for Medicaid have similar or better
health, physically and mentally, than those who were enrolled in Medicaid prior
to the roll-out of Obamacare. Additionally, chronic conditions were found to be
less common. Therefore, it may be more beneficial to expand Medicaid coverage
to those groups of Americans as managed care rates and spending may decrease
based on the health of these individuals.

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In 2014, the increase
in Medicaid spending rose across the nation which is a reflection of the
increase in Medicaid enrollment as well as an increase in costs per recipient. Along
with the rising costs of medications and an increase in payments to primary
care physicians, expanded Medicaid coverage for adults was a critical component
of increased spending rates. However, spending rates were lower for 2015, and
are projected to continue to decline annually. Medicaid spending is projected
to slow to 4.2%, which is attributed to the surge of newly eligible Medicaid
recipients, which continues to decline (CMS.gov).

Also, states reported increases
in spending in 2015 partially due to increased enrollment. Specifically, of the
states that expanded Medicaid, over half reported faster enrollment increases
than expected. And two-thirds of those states reported that costs monthly costs
per member were below earlier estimates. Also, states that did not expand
Medicaid reported a boost in spending, primarily due to increased enrollment
among previously eligible families.

Additionally, states
may utilize the increased federal matching dollars to offset effects of their
budget because of the decision to expand Medicaid coverage. This is also
indicative of cases involving those individuals who were eligible previously,
but not enrolled. Due to an increase in enrollment of this population of
Medicaid enrollees, for example, there may be an availability of federal
dollars for expenses that, at one point, was funded by the state. Additionally,
in states that expanded Medicaid, there were also reports of budgetary savings
as a result of revenue gains resulting for expansion. For example:

• A study
  in Health Affairs found that expansion lead to an 11.7
  percent increase in overall Medicaid spending, as well as a 12.2 percent
  increase in federal spending. It found no significant increases in overall
  state spending on Medicaid, no significant decreases in state spending on other
  programs, and that state spending was, in the aggregate, in line with
  projections (Sommers and Gruber, 2016).
• A 2014
  analysis of three states, Connecticut, New Mexico, and Washington by the Kaiser
  Commission on Medicaid and the Uninsured examination of three states,
  Connecticut, New Mexico, and Washington, reported state savings both within the
  Medicaid program from the enhanced matching rate and in other areas of the
  state budget, such as behavioral health and corrections (Sommers
  and Gruber, 2016).
• An issue
  brief from the State Health Reform Assistance Network looking at 11 expansion
  states indicated that as a result of Medicaid expansion, states may achieve
  savings from the enhanced matching rate as well as from replacing general funds
  with Medicaid funds, such as for services for the uninsured (Sommers and
  Gruber, 2016).

Although ACA reformed
the manner in which health coverage is delivered, it left the majority of pre-existing
insurance programs largely intact. Many Americans maintain health insurance coverage
through their employer, mostly unaffected by the provisions of ACA. When ACA began
to affect existing health coverage, it mainly expanded coverage by abolishing
annual and lifetime limits in relation to employer coverage, allowed coverage of
young adults up to age 26 to remain on their parent’s insurance plan, and/or it
closed the payment gap in drug coverage.

The most remarkable effect
of Obamacare is that it helped the uninsured to obtain coverage. Prior to 2014,
most working adults under age 65 whose employer did not offer health insurance did
not meet the eligibility standards for any public health program or subsidies
to assist with purchasing insurance. This made attaining health insurance
unaffordable. Under ACA there were two provisions to extend health insurance coverage.

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• Medicaid
  eligibility was expanded to individuals and families whose income was below
  138% of the FPL, who were not otherwise eligible.
• Tax
  credits were offered on a sliding fee scale to individuals and families whose income
  was between 100% and 400% of the FPL. These individuals were not offered
  coverage in public health programs or employer based coverage

Effective 2015,
individuals became eligible for financial assistance. To receive this
assistance, the annual income threshold could not exceed $47,080. To
illustrate, a family of four may be eligible for premium tax credit assistance
with a household income less than approximately $100,000.

Unfortunately, Medicaid
expansion did not stretch to all Americans. This is in part due to the Supreme
Court’s 2012 decision in the National Association of Independent
Business case which allowed states to “opt out” of the expansion of public
health care. This critically weakened efforts to expand Medicaid. There are millions of adults across several states that are not covered because of the
Supreme Court’s decision. Nevertheless,
ACA reduced the percentage of Americans, under age 65, who are uninsured from
about 18% to 10% (MACPAC.gov).

Moreover, while the premium tax subsidies were
successfully applied to many Americans, it continues to remain burdensome as
these subsidies have not been completely effective. Millions of middle class Americans who are enrolled in ACA backed coverage were not insured before they
obtained insurance through the provisions under ACA. But, there are millions of
Americans who continue to remain uninsured. Others are still not covered, or they
may miss out on being covered, because the premium tax credit program is so convoluted,
that they are unaware that this assistance is available to them, or because the
insurance premiums, even with the tax credit assistance, is still too costly
and health care is still unaffordable.

Improvements to Medicaid
for lower income Americans through Medicaid expansion is the end goal strategy
for expanding health care coverage to this group of individuals. There are 72 million
Americans currently enrolled in the Medicaid program which includes 13.2
million more individuals enrolled than there was in 2013, before ACA expansion.
Medicaid plays an important role for these persons because it provides access
to health care in which they otherwise cannot afford.

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The Supreme Court’s
2012 decision in National Federation of Independent Business vs Sebelius (known
as NFIB) gave states permission to opt out of the ACA’s Medicaid
expansion. There are currently twenty states that have elected to opt out of
Medicaid expansion. In an effort to make Medicaid expansion appealing to these states,
the Obama administration allowed these states some create control by providing
considerable leeway by allowing coverage through the Medicaid waiver program. However,
the degree of discretion allowed to states must remain limited in order to avoid
weakening the broader goals of ACA, which is getting states to yield to
expanding Medicaid coverage.  The federal
government can to parlay this into an opportunity to offer states further
incentives to expand Medicaid.  

Lastly, the following
should be taken into consideration in making Medicaid more beneficial to recipients
of Medicaid.

Recommendations

• The federal government should assume the cost of Medicaid expansion to all Americans.

As previously stated,
in revisiting the Supreme Court’s NFIB decision, there are twenty
states which refused to implement ACA’s Medicaid expansion, despite extremely
generous federal matching rates which are at a rate of 100%, and will dwindle
down to a set matching rate of 90% by the year 2020. The Medicaid expansion under
ACA is representative of the most substantial federal-state joint financing provisions
in the history of health policy. The Congressional Budget Office projected that
the federal government will cover over 93% of costs associated with Medicaid
expansion between 2014 and 2022 (2014). The added cost for states is projected
to increase by 2.8%. The states would have spent this on Medicaid regardless of
the health care reforms associated with Obamacare (Congressional budgeting
office, 2017). In fact, studies show that Medicaid expenditures are increasing
at a more rapid rate in states that opted to not expanded Medicaid than those states
that have (Congressional budgeting office, 2017).

A further review of economic
analyses shows that the economic impact of Medicaid expansion, locally, is extremely
favorable to state government budgets as well as state economies. Therefore,
funding provided as a result of Medicaid expansion, regularly serves as a
replacement for state expenditures.

Despite these
benefits, state administrators and citizens are concerned about the amount of
federal monies associated with Medicaid expansion as a result of ACA. It is
more effective for the federal government to assume all the costs associated
with the expansion for all states. Since the federal government is already footing
an overwhelming majority of costs to insure a fairly healthy population, this
would require a tiny amount of added federal funding which equates to about
$5.2 billion to cover the 11.9 million newly eligible adults in calendar year
2020 (MACPAC.gov)

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• Develop a counter-cyclical system for funding Medicaid.

A counter-cyclical
system ensures funding for public programs to deal with any budgetary
shortfalls. This could be done by following the funding scheme that the
unemployment insurance program follows.

Both state and federal
governments have an established unemployment insurance trust fund. The federal
government can place funds associated with Medicaid into a trust, divided by
state. Therefore, when the costs associated with health care arise, Medicaid
has a monetary safety net available to them to cover these additional costs. Additionally,
this type of system would also be beneficial for CHIP when there is an increase
in demand for this program.

Conclusion

A review of Medicaid
and CHIP was conducted. These programs were initially available to families as
a component of welfare payments. With the enactment of reformative legislation,
for more than two decades, Medicaid evolved considerably. These changes allowed
for Medicaid to be its own separate entity, aside from AFDC payments. This
change no longer precluded certain individuals from being eligible for the
Medicaid program, but because of strict income guidelines, it still prohibited
many Americans from access to public health care.

With the
implementation of the Affordable Care Act, also known to the public as
Obamacare, there were considerable incentives to cover more uninsured Americans
by expanding public health insurance coverage. However, states did not buy-in
to the idea of increased spending. But a detailed analysis proved that the
costs associated with insuring all Americans under a public health option will
not “break the bank” as previously thought. In fact, the cost to insure the
uninsured will have little to no change on the bottom line. Therefore,
expansion of Medicaid and CHIP programs will be beneficial, attainable, and
more importantly cheaper.   

The provisions under
the Affordable Care Act made coverage affordable and attainable for many
Americans. This enabled coverage for many Americans. However, if fell short
because Americans found that the costs-sharing was too expensive. The cost of
premiums which included premium tax credits to assist with costs were not
enough to provide much needed coverage to those individuals.

The expansion of
Medicaid would remedy this. Medicaid is the largest provider of insurance
coverage. And costs are covered by the federal government at over 90%. Individuals
who would derive eligibility through expansion are found to be healthier than
those who are eligible for Medicaid. Thus, the cost to insure more Americans
will not rise as once believed. Therefore, making Medicaid the insurer of all
Americans will be more cost effective in the long-run.

Bibliography

• Amadeo, K. (n.d.). How the Affordable Health Care Act Affects You. Retrieved December 3, 2017, from https://www.thebalance.com/2010-patient-protection-affordable-care-act-3306063
• Baughman, R. (2007). Differential impacts of public health insurance expansions at the local level. International Journal of Health Care Finance and Economics, 7(1), 1-22. doi:10.1007/s10754-007-9009-8
• Amadeo, K. (n.d.). How the Affordable Health Care Act Affects You. Retrieved December 3, 2017, from https://www.thebalance.com/2010-patient-protection-affordable-care-act-3306063
• Devoe, J. E., Tillotson, C. J., Wallace, L. S., Selph, S., Graham, A., & Angier, H. (2011). Comparing Types of Health Insurance for Children. Medical Care, 49(9), 818-827. doi:10.1097/mlr.0b013e3182159e4d
• Dubay, L., & Kenney, G. M. (spring 1996). The Effect of the 2014 Medicaid Expansion on F. (n.d.). Facts on the Affordable Care Act. Retrieved December 06, 2017, from https://obamacarefacts.com/obamacare-facts/
• Frean, M., Gruber, J., & Sommers, B. (2016). Premium Subsidies, the Mandate, and Medicaid Expansion: Coverage Effects of the Affordable Care Act. doi:10.3386/w22213
• Gottlieb, S. (2015, July 05). How the Affordable Care Act Is Reducing Competition. Retrieved November 29, 2017, from http://www.wsj.com/articles/how-the-affordable-care-act-is-reducing-competition-1436136236
• Helfgott, M. S. (2012, February 03). A Comparison of the Canadian and U.S. Healthcare Systems. Retrieved November 03, 2017, from http://www.the- rheumatologist.org/article/a-comparison-of-the-canadian-and-u-s-healthcare-systems/2/
• Helfgott, S. M. (2017, November 26). Comparison of the health care systems in Canada and the United States. Retrieved December 01, 2017, from             https://en.wikipedia.org/wiki/Comparison_of_the_health_care_systems_in_Canada_and_ the_United_States
• Insurance Coverage for Newly Eligible Childless Adults. The Future of Children, 6(1). doi:10.7249/rr1736
• Lewit, E. M., Bennett, C., & Behrman, R. E. (2003). Health Insurance for Children: Analysis and Recommendations. Health Insurance for Children, 13(1), 4-29.
• Mann, C., Rowland, D., & Garfield, R. (2003). Historical Overview of Childrens Health Care Coverage. The Future of Children, 13(1), 30. doi:10.2307/1602638
• Medical Expansion . (n.d.). Retrieved December 03, 2017, from https://www.macpac.gov/
• National Center for Health Statistics. (2017, March 31). Retrieved December 1, 2017, from https://www.cdc.gov/nchs/fastats/health-insurance.htm
• Palacios, M., Barua, B., & Ren, F. (2015). The Price of Public Health Care Insurance. FraseInstitute Research Bulletin. Retrieved August, 2015.
• State and federal spending under the ACA. (n.d.). Retrieved December 01, 2017, from https://www.macpac.gov/subtopic/state-and-federal-spending-under-the-aca/
• Swigonski, N. L. (2001). Pushing the Envelope—Health Care, Not Welfare. Medical Care, 39(6), 521. doi:10.1097/00005650-200106000-00001
• Stoltzfus Jost, T., & Pollack, H. (2016, August 25). Key Proposals to Strengthen the Affordable Care Act. Retrieved December 1, 2017, from https://tcf.org/content/report/key-proposals-to-strengthen-the-aca/
• Wysen, K., Pernice, C., & Riley, T. (2003). How Public Health Insurance Programs for Children Work. The Future of Children, 13(1), 170-191. doi:10.2307/1602647
• United States, Department of Health and Human Services, Centers for Medicare and Medicaid Services. (n.d.). www.Medicaid.gov.

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[1] The Centers for Disease Control and Prevention (CDC) provides the
latest statistical data available regarding the numbers of uninsured Americans
after the effectuation of the Affordable Care Act.

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[2] This article provides a complete overview of the Medicaid and CHIP
programs from its inception as a Depression-era answer to providing medical
coverage to families and children. The program became widely known as the Aid
to Families with Dependent (AFDC). An overhaul of AFDC de-linked Medicaid from
welfare payments thereby making eligibility for public health coverage solely
based on income.

[3] The Children’s Health Insurance Program (CHIP) is funded by block
grants which have propensity to run low on funding. Because CHIP is funded by
block grants, there is an expiration and Congress must decide to expand this
program which continues to insure millions of children.

[4] Table 1 provides a statistical breakdown of the percentage of
uninsured adults and Children as well as the costs associated with insuring
these populations.

[5] As an incentive to expanding Medicaid, the federal government
agreed to allocate 100% of the funding for Medicaid for the first three years
of expansion. Thereafter, Medicaid funds allocation will be provided to states
by the federal government at a rate of 90%. States will only have to provide a
10% allocation match.

[6] These listed factors are what insurers are mandated to provide in
coverage under the provisions of ACA.

[7] Table 2 provides the cost-sharing breakdown of private insurance
plans available under the ACA. Americans can select the plans based on their
health care needs. The premium payments are based upon the type of coverage
selected, the income of the individual or household, and the premium tax
subsidy.

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[8] This article provides a comprehensive analysis of the amount of
funding that was rolled into Obamacare at its inception.

[9] This bulletin provided the financial analysis of the cost of
universal healthcare in Canada.

[10] Table 3 provides the breakdown of healthcare spending in Canada on
average in comparison to other expenditures.

[11] Family-Related Medicaid. (2017, February 01). Retrieved December
01, 2017, from http://www.myfloridafamilies.com/medicaid

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