A middle road for Medicaid expansion?

April 7, 2014, University of Michigan Health System

With the political divide over health care reform still strong going into this year's elections, a new analysis of state-level decisions shows signs of an emerging middle way toward reducing the ranks of the uninsured.

The approach centers on efforts by governors and legislatures to get federal permission to customize Medicaid expansion in ways that satisfy political conservatives – while still allowing them to collect federal funding to increase in their state.

In a new Viewpoint published online by the Journal of the American Medical Association, a team from the University of Michigan assesses the results so far.

They focus on two major Affordable Care Act-related decisions: whether to create a state health insurance exchange, and whether to expand Medicaid eligibility to low-income adults, which comes with full federal funding at first and phases in state contributions over several years. They also look ahead to potential issues that may arise as ACA-related Medicaid waivers granted to certain states hit new milestones.

The team, from the U-M School of Public Health, Medical School and Institute for Healthcare Policy and Innovation, find that only 15 states and the District of Columbia have chosen to fully comply with the ACA as originally designed by creating a state-based exchange and expanding Medicaid. But 23 states took neither of these steps.

Partisan politics plays a role, they find. All but two of the 15 states that started their own exchange and expanded Medicaid are led by Democratic governors, and all but three of the 23 states that did neither are led by Republican governors.

But party control doesn't tell the whole story, they say. In all, 11 states expanded Medicaid and went with the federal or a federal-state partnership exchange, including six led by Republican governors.

One of them, Michigan, just began enrolling residents in its Healthy Michigan Plan on April 1, and initial reports suggest rapid and smooth progress. Idaho is the only state to have said no to Medicaid expansion but created a state exchange.

"This is clearly an important issue because of the coverage gap that will leave nearly 6 million people uninsured who are living below the poverty level or just above it in states that don't expand Medicaid," says Phillip Singer, MHSA, one of two U-M doctoral students who carried out the analysis.

He and his colleagues focused on the waivers that conservative-leaning states have asked the federal government to approve, allowing them to customize the Medicaid program during expansion.

"Each state seems to be pushing a little further to tailor the Medicaid program to fit their political ideology, and we don't know where this is going to end or where the federal government will say a state has gone too far," says Singer, who is working toward a degree in the U-M School of Public Health's Health Services Organization and Policy program.

The team compiled data on the current state of Medicaid expansion and state-level insurance exchanges across the country. Co-author David Jones, MSPH, MA, also conducted interviews over nearly three years with leaders in 25 states as part of his doctoral work in the same program.

Senior author John Ayanian, M.D., MPP, explored the politics of Michigan's Medicaid expansion and its potential as a model for other Republican-governed states in a previous article in the New England Journal of Medicine. (Summary available here)

Arkansas and Iowa also sought waivers, and Indiana and Pennsylvania currently have proposed waivers before the federal Department of Health and Human Services, with other states such as Missouri and Utah working toward possibly proposing waivers in order to customize Medicaid.

The waivers states have sought allow or would allow them to include conservative-favored options in expanded Medicaid programs, including cost-sharing, health savings accounts, and financial incentives for healthy behaviors or disincentives for certain health care-related actions – for example visiting an emergency department for a condition that could have been treated in a primary care clinic.

"These waivers are very important politically, enabling governors to persuade enough conservatives in their legislatures to support a modified Medicaid expansion," says Ayanian, who is the Alice Hamilton Collegiate Professor of Medicine in the Medical School's Department of Internal Medicine. "This approach allows Republicans to pursue Medicaid waivers they view as beneficial for their states without endorsing other components of the ACA." A member of the Division of General Medicine, Ayanian is also a professor in the U-M School of Public Health and the Ford School of Public Policy.

Over the next six years, as waivers begin to expire and states must begin to shoulder part of the expense of people enrolled under expanded Medicaid criteria, the political tides will play a major role in whether states continue to participate, the authors predict.

"Waivers are a way for Republican governors and legislators to say they are reforming Medicaid instead of embracing Obamacare, while still accepting federal money available because of the Affordable Care Act," says Jones. "Hospitals, providers, and small businesses are advocating strongly in favor of Medicaid expansion. But there are many states where any chance of Medicaid expansion will depend on policymakers finding a middle way."

The current state harkens back to the original creation of Medicaid in 1965 – and the slow process of getting the second half of states to sign on, with Arizona finally joining in 1983. But, the U-M authors say, the federal waiver process gives much more flexibility than they had when Medicaid was launched.

Explore further: Federal data show health disparities among states

Related Stories

Federal data show health disparities among states

December 12, 2013
The slow rollout of a new federal health insurance marketplace may be deepening differences in health coverage among Americans.

Model Arkansas way of expanding Medicaid at risk

February 6, 2014
Less than a year after its approval, Arkansas' much-heralded plan to expand Medicaid by buying private insurance for the poor instead of adding them to the rolls is on the brink of being abandoned. Supporters are worried ...

'Coverage gap' likely to affect 5.2 million uninsured adults

October 18, 2013
(HealthDay)—About 5.2 million uninsured adults are expected to fall into the Affordable Care Act (ACA) 'coverage gap,' with incomes too high to qualify for Medicaid programs but below the level eligible for federal subsidies ...

Medicaid expansion may help prevent kidney failure, improve access to kidney-related care

March 20, 2014
States with broader Medicaid coverage have lower incidences of kidney failure and smaller insurance-related gaps in access to kidney disease care. Those are the findings of a study appearing in an upcoming issue of the Journal ...

States to get Medicaid cases from federal website

December 17, 2013
Federal officials are working to send states the applications of Medicaid-eligible people who sought health insurance through the troubled new federally run marketplace.

Expanding medicaid is best financial option for states, study finds

June 3, 2013
States that choose not to expand Medicaid under federal health care reform will leave millions of their residents without health insurance and increase spending, at least in the short term, on the cost of treating uninsured ...

Recommended for you

Americans are getting more sleep

January 19, 2018
Although more than one in three Americans still don't get enough sleep, a new analysis shows first signs of success in the fight for more shut eye. According to data from 181,335 respondents aged 15 and older who participated ...

Wine is good for you—to a point

January 18, 2018
The Mediterranean diet has become synonymous with healthy eating, but there's one thing in it that stands out: It's cool to drink wine.

Sleep better, lose weight?

January 17, 2018
(HealthDay)—Sleeplessness could cost you when it's time to stand on your bathroom scale, a new British study suggests.

Who uses phone apps to track sleep habits? Mostly the healthy and wealthy in US

January 16, 2018
The profile of most Americans who use popular mobile phone apps that track sleep habits is that they are relatively affluent, claim to eat well, and say they are in good health, even if some of them tend to smoke.

Improvements in mortality rates are slowed by rise in obesity in the United States

January 15, 2018
With countless medical advances and efforts to curb smoking, one might expect that life expectancy in the United States would improve. Yet according to recent studies, there's been a reduction in the rate of improvement in ...

Can muesli help against arthritis?

January 15, 2018
It is well known that healthy eating increases a general sense of wellbeing. Researchers at Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU) have now discovered that a fibre-rich diet can have a positive influence ...


Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.