CALIFORNIA STATE UNIVERSITY, NORTHRIDGE

Affordable Care Act: The Effects of Not Expanding Medicaid

A Graduate Project Submitted in Partial Fulfillment of the Requirements for the Degree of

Master of Public Administration, Health Administration

By

Judith Chandrasena

August 2021

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The Graduate Project of Judith Chandrasena is Approved:

____________________________________ ____________________________

Dr. David Powell Date

_________________________________________ ___________________________

Dr. Frankline Augustin Date

_________________________________________ ___________________________

Dr. Kyusuk "Stephan" Chung, Chair Date

California State University, Northridge

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Table of Contents

Signature Page………………………………………………………………………………….…ii

Abstract……………………………………………………………………………………………v

Introduction ..................................................................................................................................... 1

Literature Review............................................................................................................................ 4

Medicaid ..................................................................................................................................... 4

Medicaid Programs and Eligibility ............................................................................................. 4

Children's Health Insurance Program (CHIP) ........................................................................ 4

Basic Health Program ............................................................................................................. 5

Opt-Out States ............................................................................................................................. 6

Adopted ACA but Not Implement .............................................................................................. 8

Socioeconomic Consequences .................................................................................................... 9

Population Health...................................................................................................................... 10

If States were to Repeal ACA ................................................................................................... 11

Cost of Healthcare in Non-Expansion States ............................................................................ 14

Texas ..................................................................................................................................... 14

Wyoming............................................................................................................................... 15

Cost of Healthcare where ACA is Adopted .............................................................................. 17

California & New York ........................................................................................................ 17

Economic Effects of Medicaid Non-Expansion States on Hospitals ........................................ 20

Methodology ................................................................................................................................. 22

Methodology Chart ................................................................................................................... 24

Findings/Analysis ......................................................................................................................... 25

Positive Health Outcomes ......................................................................................................... 25

States' Economics and Politics .................................................................................................. 26

American Rescue Plan Act ....................................................................................................... 27

Policy Implications ....................................................................................................................... 30

Conclusion .................................................................................................................................... 33

References ..................................................................................................................................... 35

Appendix: List of Figures ............................................................................................................. 44

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Abstract

Affordable Care Act: The Effects of Not Expanding Medicaid

By

Judith Chandrasena

Master of Public Administration, Health Administration

One of The Affordable Care Act (ACA) 's main goals is to increase access in the United States

through insurance marketplace reforms, mandates, and Medicaid Expansion which started to take

effect in 2014. Medicaid Expansion offered coverage and affordability to all citizens, primarily to

those in poverty. States that did not expand Medicaid have gone through much scrutiny due to the

lack of coverage to its citizens and the lack of compensation to the hospitals and providers. The 12

states that opted out of the ACA failed to provide an alternate medical coverage plan for their

citizens. This literature review, through qualitative analysis, examined the socioeconomic,

population health, and economic effects on hospitals in non-expansion states through contrasting

the expansion and non-expansion of Medicaid through the country.

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The consequences of opting out contributed to poor population health in that people are hesitant

to seek medical care for fear of incurring medical bills. Physicians and hospitals are in a bind

because they must render medical attention, knowing that they will not get adequate funding to

stay in business. The federal government purposefully withholds additional funding for Medicaid

as an incentive to try and get the 12 states to adopt slow but steady progress. Additional policy

efforts are needed to encourage non-expansion states to expand Medicaid.

1

Introduction

As of July 2021, 39 states (including DC) have adopted the Medicaid expansion, and 12

states have not adopted the expansion (U.S. Centers for Medicare & Medicaid Services, 2018).

The Obama administration explained that states who refused funding for Medicaid expansion

were making a political point. The 12 non-expansion states are Republican-led states (Leonard,

2015). Some lawmakers expressed that they do not trust the federal government about honoring

its commitment to keep up the level of support over the long term. The individual mandate –

which requires most people to maintain health insurance coverage or pay the penalty (Kamal et

al., 2018) of 10% cost is too much for their already-strained budgets (Leonard, 2015). In

addition, states believed that Washington should give them greater control over spending to

better fit coverage expansion within their states (Turner, 2013).

The Affordable Care Act (ACA) offers medical insurance to uninsured Americans,

including preventive and primary care services. The legislation is built on a multi-prong

framework - cost, access, and quality. First, the ACA promises to make health insurance

affordable to all Americans and covers 138% below the federal poverty level. Second, the Act

codified protections for preexisting conditions and eliminated patient cost-sharing for high-value

preventive services. Last, the law goes beyond coverage, requiring employers to provide

breastfeeding mothers with breaks at work, making calorie counts more widely available in

restaurants, and creating the Prevention and Public Health Fund. This law helps the Centers for

Disease Control and Prevention (CDC) and state agencies detect and respond to health

threats such as COVID-19 (Rapfogel et al., 2020).

Medicaid expansion ultimately contributes to population health improvement (Kino &

Kawachi, 2018. Vulnerable populations are particularly at risk for insufficient health insurance

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coverage; people with lower incomes are often uninsured, and minorities account for over half of

the uninsured population. Inadequate health insurance coverage is one of the most significant

barriers to healthcare access, and the unequal distribution of the coverage contributes to

disparities in health. Out-of-pocket medical care costs may lead individuals to delay or forgo

needed care, such as doctor's visits, dental care, and medication. In addition, medical debt is

common among insured and uninsured individuals (Access to Health Services | Healthy People

2020, 2020).

This thesis comprises various literature reviews that focus on the 12 states that did not

adopt the ACA expansion. First, a brief definition of what Medicaid is is discussed. Then,

programs under Medicaid that provide health insurance coverage to children, the Children's

Health Insurance Program (CHIP), and the Basic Health Programs for adults that meet the

federal poverty level are assessed. States that opt-out of Medicaid expansion is looked at closely,

evaluating the effects of non-expansion. The findings exposed the cost of the uninsured to the

healthcare system and the vulnerability to population health. Medicaid expansion is associated

with a 4.4% to 4.7% reduction in state spending on traditional Medicaid. For example, Medicaid

spending on mental health care within the correctional system and a decrease in uncompensated

care range from 14% of the expansion cost in Kentucky to 30% in Arkansas (Ward, 2020). The

literature review showed how individual mandates affect enrollment decisions and assess the

effects of eliminating the penalty on enrollment, premiums, and the federal deficit (Eibner &

Nowak, 2019). The Supreme Court ruling allowed the states the choice to expand. The results of

states decisions are evident in every literature review. The burden of care has fallen on the states.

First, a brief description of what Medicaid is, the kind of programs under Medicaid, what states

did and did not adopt the ACA, the socioeconomic and overall population health, and the

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economic consequences of the failure to adopt are provided. Next, a comparison is made

between states that adopted the ACA expansion and states that opt-out. The evidence showed the

differences in cost, access to healthcare for the vulnerable, and the difference in a healthier

population.

This research concludes by showing how expansion to Medicaid proves that individuals

with coverage improve overall health (Kagan & Catalano, 2019). First, the adoption of the ACA

reduces financial burdens significantly. Second, uninsured patients' costs are "absorbed" by the

federal government, localities, and states that support the operation of hospitals and clinics, both

through appropriations and implicit subsidies like Medicare and Medicaid. Lastly, philanthropic

donations are depleted (Institute of Medicine (US) Committee on the Consequences of

Uninsurance, 2003). Fourth, Medicaid expansion increases cost by increased usage of medical

resources. However, these factors still outweigh increased revenue by Medicaid expansion (Stan

Dorn et al., 2014).

4

Literature Review

Medicaid

Medicaid is a public insurance program created in 1965 and authorized by Title XIX of the

Social Security Act (Program History | Medicaid.gov, 2015). All states, the District of

Columbia, and the U.S. territories have Medicaid programs designed to provide health coverage

for low-income families and individuals, including children, parents, pregnant women, seniors,

and people with disabilities. Funding for Medicaid is a joint effort between the federal

government and states. Each state is responsible for how the program operates, provided that

they are operating within federal guidelines (Policy Basics: Introduction to Medicaid, 2020).

Medicaid Programs and Eligibility

Children's Health Insurance Program (CHIP)

In 2018, Medicaid provided health coverage for 97 million low-income Americans over

the course of the year. In any given month, Medicaid served 32 million children, 28 million

adults (mostly in low-income working families), 6 million seniors, and 9 million people with

disabilities, according to Congressional Budget Office (CBO) estimates (Policy Basics:

Introduction to Medicaid, 2020). The Children's Health Insurance Program (CHIP), signed into

law in 1997, provides health coverage to eligible children through both Medicaid and separate

CHIP programs. As of 2018, 9.6 million children are enrolled in the CHIP program (Benefits |

Medicaid.gov, 2013). CHIP ensures mandatory benefits. For example, Well-Baby and Well-

Child are mandatory in each state, and they have the flexibility to determine the periodicity

schedule that defines when those visits should occur (Benefits | Medicaid.gov, 2013). Most states

use the schedules recommended by the American Academy of Pediatrics or Bright Futures to

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organize the periodicity schedule. The schedule mandates dental visits, behavioral health

benefits, and vaccines (Bright Futures, 2019).

After declines in enrollment from 2017 through 2019, total Medicaid/CHIP enrollment

grew to 81.0 million in February 2021, an increase of 9.8 million from enrollment in February

2020 (13.8%), right before the pandemic and when enrollment began to steadily increase as

shown in figure 1. Increases in enrollment reflect changes in the economy (as more people

experience income and job loss and become eligible and enroll in Medicaid and CHIP coverage)

and provisions in the Families First Coronavirus Response Act (FFCRA) that require states to

ensure continuous coverage to current Medicaid enrollees to access a temporary increase in the

Medicaid match rates. Enrollment may continue to grow even as the economy recovers from the

effects of the pandemic and the Medicaid Open Enrollment (MOE) remains in place (Corallo &

2020, 2020).

Figure 1

Basic Health Program

The Basic Health Program (BHP) enacted by the ACA in 2providesvide states the option to

establish health benefits to cover programs for low-income residents who would otherwise be

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eligible to purchase coverage through the Health Insurance Marketplace (Benefits |

Medicaid.gov, 2013). This program provides affordable coverage for individuals whose income

fluctuates above and below Medicaid and CHIP levels. The income level required is 200% of the

federal poverty level (FPL), and consumers would otherwise qualify for subsidies in the

marketplace. In addition to meeting income requirements, BHP-eligible consumers must be state

residents, age 64 or younger, U.S. citizens or lawfully present immigrants, and ineligible for

other minimum essential coverage, including Medicaid, CHIP, and affordable insurance offered

by an employer. BHP consumers are enrolled in "standard health plans" that cover the ten

Essential Health Benefits required of QHPs in the marketplace. BHP premiums and out-of-

pocket cost-sharing may not exceed what would have been charged by the benchmark plan

(second-lowest-cost silver plan) in the marketplace, considering premium tax credits (PTCs) and

cost-sharing reductions (CSRs) for which consumers would have qualified (Dorn, November 25,

et al., 2014).

State and local officials will be responsible for reaching out to and enrolling more than 30

million individuals in publicly funded or subsidized health plans offered through state insurance

exchanges. Failure to meet enrollment goals will not only undermine the credibility and success

of the Patient Protection and Affordable Care Act (ACA) but, more importantly, will do little to

expand health insurance coverage and improve access to care among those at greatest need

(Martin & Parker, 2011).

Opt-Out States

The U.S. Supreme Court's ruling on the Affordable Care Act in 2012 allowed states to opt-out of

the health reform law's Medicaid expansion. Since that ruling, fourteen governors have

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announced that their states will not expand their Medicaid programs seen in figure 2. It is

estimated that 3.6 million fewer people would be insured, federal transfer payments to those

states could fall by $8.4 billion, and state spending on uncompensated care could increase by

$1 billion in 2016, compared to what would be expected if all states participated in the expansion

(Price & Eibner, 2013).

Figure 2

Status of State Action on the Medicaid Expansion Decision

In the states that have not expanded Medicaid, there is a coverage gap that leaves

about 2.5 million people ineligible for any sort of affordable coverage. And according to U.S.

Census data, the percentage of people below the poverty level who are uninsured is more than

twice as high in states that have not expanded Medicaid compared with states that have. Five

states — Texas, North Carolina, Florida, Georgia, and Tennessee — account for the lion's share

of the coverage gap population (healthinsurance.org, 2018). If Medicaid is expanded in North

Carolina, Gov. Roy Cooper's administration estimates that 624,000 residents would become

newly eligible for coverage. A significant number of them (estimates range

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from 215,000 to nearly half a million) are currently in the coverage gap, with no realistic access

to health insurance at all unless Medicaid is expanded. The federal government paid the full cost

of expansion through 2016. In 2017, states began to pay 5 percent of the cost, and that will

increase to 10 percent by 2020. The states' portion will never exceed 10 percent, though. In

North Carolina, the state's cost to expand Medicaid is estimated at between $210 million and

$600 million per year (Norris, 2020).

Adopted ACA but Not Implement

Only one state decided to adopt the ACA but is hesitant to implement the expansion. On August

4, 2020, Missouri voters approved a ballot measure that added Medicaid expansion to the state's

Constitution and required the implementation of expansion coverage by July 1, 2021. However,

on May 13, 2021, Governor Mike Parson announced that the state's Department of Social

Services (DSS) was withdrawing its state plan amendment (SPA) submission and would not

implement expansion as scheduled due to a lack of funding: the ballot measure did not include a

revenue source and the state legislature excluded the program from its F.Y. 2022 budget.

Subsequently, on May 20, advocates filed a lawsuit against the DSS, arguing that the state's

refusal to expand Medicaid is unlawful per the initiated constitutional amendment and asking

that the court require expansion to go into effect on July 1, 2021. On June 23, a circuit court

judge ruled in favor of DSS, finding that the state's refusal to expand Medicaid is not unlawful

because the initiated amendment violated the state constitution by failing to provide a funding

source. However, on July 22, the Missouri Supreme Court overturned this decision, finding that

the initiated amendment did not violate the state constitution and instructing the lower court to

enter a judgment in favor of the plaintiffs. Pending this judgment, the timeline for Medicaid

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expansion implementation remains unknown. Under the American Rescue Plan Act's incentive,

Missouri could receive an estimated $1.1 billion in additional federal funds over the next two

years for the traditional Medicaid program if the state implements the Medicaid expansion.

Language in the initiated constitutional amendment prohibited the imposition of any additional

burdens or restrictions on eligibility or enrollment for the expansion population.

(KFF, 2019).

Socioeconomic Consequences

Health insurance coverage helps increase access to health care services, including preventive and

primary care, and ultimately could contribute to population health improvement. The ACA

expansion was associated with a reduction in the uninsured rate while increasing the use of some

health services, such as outpatient visits and overnight hospital stays, as well as the use of

preventive services (e.g., screening visits and check-ups including cholesterol screening, Pap

smear tests, mammograms, and PSA tests) (Kino & Kawachi, 2018).

Access to health care among non-elderly Americans is strongly associated with

socioeconomic characteristics, including income, education, employment, and wealth. Compared

to Americans who are better off, those in lower socioeconomic strata are less likely to be insured

and more likely to avoid medical care due to cost, enter hospitals through emergency

departments and have twice as many avoidable hospitalizations. The poor use less health care in

spite of having greater medical needs. These health care access gaps are compounded by—and

may contribute to—the large and widening socioeconomic disparities in health and longevity in

the United States (Griffith et al., 2017).

The challenge in reaching medically underserved communities is that Medicaid

beneficiaries are more likely to live in medically underserved communities that frequently lack the

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providers essential to building quality networks. Safety-net providers such as community health

centers and public and mission-driven hospital systems form the Medicaid managed care provider

network backbone, but they, too, experience staff shortages. One recent study reported that simply

by filling open positions, health centers could serve 2 million more patients.

Another challenge is those who have unstable eligibility and enrollment. Eligibility for

both Medicaid and the tax subsidies offered through the ACA's insurance marketplaces is closely

tied to family income. Even with the massive efforts now underway to streamline enrollment and

renewal, nothing can overcome the income fluctuations that can cause coverage shifts over time.

The risk of breaks in coverage remains, especially in states that have chosen not to expand Medicaid

eligibility. Therefore, the rule's emphasis on making it possible for health plans to participate in both

the Medicaid managed care market and the qualified health plan marketplace so that people can

remain enrolled in their plans represents a key opportunity for states (Rosenbaum, 2016).

Population Health

Population health is defined as the health outcomes of a group of individuals, including the

distribution of such outcomes within the group (Kindig & Stoddart, 2003). It is a relatively new

term with no agreement about whether it refers to a concept of health or a field of study of health

determinants. Discussions of population health involve many terms, such

as outcomes, disparities, determinants, and risk factors, which may be used imprecisely,

particularly across different disciplines, such as medicine, epidemiology, economics, and

sociology. Nonetheless, thinking and communicating clearly about population health concepts

are essential for public and private policymakers to improve the population's health and reduce

disparities (Chang et al., 2021).

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If States were to Repeal ACA

If the ACA were repealed, the number of uninsured people in the U.S. would increase to 50.3

million, an increase of 65.4 percent or 19.9 million people seen in figure 3. Medicaid and CHIP

enrollment would fall by 15.4 million people through the elimination of the ACA's Medicaid

expansion. Reduced Medicaid eligibility would increase uninsurance among the low-income

population seen in figure 3 (Blumberg et al., 2019).

Figure 3

Though it is estimated that about 88 percent of nongroup coverage under current law is ACA

compliant, post repeal nongroup coverage would not be required to meet ACA consumer

protections unless states passed them into law. Without the ACA's federal tax credits to attract

many healthy people into the nongroup insurance market, those consumer protections could not

be maintained because of the risk of substantial adverse selection into the market. Therefore,

those enrolling in private nongroup coverage after repeal would likely have policies that cover

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significantly fewer benefits and require more out-of-pocket spending for services, five like

nongroup coverage before ACA implementation. These policies also would no longer be

required to cover preexisting conditions. Because of the elimination of guaranteed issues and

modified community ratings, many people with current or past health problems would be unable

to purchase the plans at any price, and others would be charged very high prices for insurance

policies, further decreasing coverage and increasing financial burdens (Blumberg et al., 2019).

The largest absolute increase in the number of uninsured people occurs in the largest states: 3.8

million more uninsured in California, 1.6 million more uninsured in Florida, and 1.7 million

more uninsured in Texas. The largest percentage increases in the uninsured would occur in the

states, with the largest increases in coverage under the ACA. For example, West Virginia and

Kentucky have large low-income populations and had high uninsurance rates before the ACA,

and both states expanded Medicaid eligibility in 2014 (Blumberg et al., 2019). Under a repeal,

the number of people uninsured in Kentucky would increase by 379,000, or 150.5 percent; in

West Virginia, the number of people uninsured would increase by 162,000, or 175.6 percent. The

uninsured in Montana, another ACA Medicaid expansion state, would increase by 176.8 percent,

or 112,000 people. States that did not expand Medicaid and/or did not have measures in place to

encourage high Marketplace enrollment would see much smaller changes in their number of

uninsured residents under repeal. For example, uninsurance in South Dakota would increase by

12,000 people, or 11.9 percent; uninsurance in Kansas would increase by 62,000 people, or 18.0

percent (Blumberg et al., 2019).

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Figure 4

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Cost of Healthcare in Non-Expansion States

Texas

Health care spending represents nearly half of the state budget. In fiscal 2015, Texas

spent $42.9 billion on health care, or 43.1 percent of all its appropriations from state,

federal, and other sources. About 42 percent of this spending came from state general

revenue, including dedicated accounts within general revenue. Federal funds covered

43.6 percent, while the remainder came from grants, interagency contracts, and other

sources. State government health care spending rose by 19.7 percent from fiscal 2011 to

2015, exceeding the growth of inflation and the Texas population during the same time

shown in figure 5 (Texas, 2017).

Figure 5

Five state agencies — the Texas Health and Human Services Commission (HHSC),

Texas Department of Aging and Disability Services (DADS), Texas Department of

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State Health Services (DSHS), Employees Retirement System (E, RSS), and Teacher

Retirement System (TRS) — accounted for 82.5 percent of all health care spending in

fiscal 2015 (Texas, 2017).

Figure 6

Wyoming

Because Wyoming has not expanded Medicaid (and is thus missing out on hundreds of

millions of dollars in federal funding), the state has 12,000 people in the coverage gap, with no

access to financial assistance with their health insurance. They would be eligible for Medicaid

coverage if Wyoming were to accept federal funds to expand coverage under the ACA. In all,

about 20,000 people would become newly eligible for Medicaid if the state were to expand

coverage, including people with income between 100 percent and 138 percent of the poverty

level, who are currently eligible for premium subsidies in the exchange seen in figure 7. "We've

turned down approximately $500 million in federal funding, which is just ridiculous," said

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Democratic candidate Mary Throne, adding that the decision should be a "no-brainer" (Health

insurance in Wyoming: find affordable coverage, 2020).

Figure 7

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Total enrollment in Medicaid/CHIP in Wyoming stood at 62,643 people as of September 2020,

which was a drop of 7 percent since 2013 (but it had been even lower in late 2019 when total

enrollment was 20 percent lower than it had been in 2013; enrollment in Medicaid has increased

nationwide during the COVID pandemic, even in states that have not expanded Medicaid

eligibility under the ACA). Nationwide, Medicaid/CHIP enrollment is up by 35 percent since

2013. As of September 2020, Wyoming was the only state where Medicaid enrollment was still

below what it had been in 2013.

Figure 8

Cost of Healthcare where ACA is Adopted

California & New York

California's implementation of the Affordable Care Act (ACA) has been the most

successful in the nation and is, in many ways, a model of how a managed competition

marketplace is expected to work. In particular, the state's decision to structure its marketplace as

an active purchaser has contributed to premium increases that are lower than in almost all other

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states. Relative concentrations of insurers and particularly of providers in the different rating

regions of the state are the fundamentals that matter most in the effort to bend the health

insurance cost curve (Weinberg & Kallerman, 2017).

The four largest states in the U.S.—California, Florida, New York, and Texas—fall into two

distinct categories. The first group is represented by California and New York, both of which are

operating their own health insurance marketplaces and have expanded eligibility for Medicaid to

adults who earn at or below 138 percent of the federal poverty level—about $16,000 for an

individual or $32,000 for a family of four.3 Florida and Texas, the second group, are using the

federal marketplace to enroll residents in health plans and have declined to expand Medicaid

eligibility. In this new analysis of data from the Commonwealth Fund Biennial Health Insurance

Survey, we find that there were larger shares of uninsured adults in Florida and Texas compared

with California and New York in 2014. In addition, adults in Florida and Texas were more likely to

report not getting needed care because of cost and having problems paying medical bills.

Figure 9

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Young adults have experienced the largest gains in coverage nationally. According to the survey, by

2014, the national uninsured rate for 19-to-34-year-olds was 19 percent. This was down from 27

percent in 2010—the year adult children became eligible to remain on parents' health plans to age

26.8 There are differences among the four states. In New York, 14 percent of young adults were

uninsured in 2014, compared with 34 percent in Texas, 26 percent in Florida, and 23 percent in

California (Rasmussen et al., 2015).

There are also significant differences in coverage rates for adults with low incomes. Adults

with incomes below 100 percent of the federal poverty level—that is, $11,490 for an individual or

$23,550 for a family of four—are faring best in New York and California (figure 10). Thirteen

percent of low-income New Yorkers and 23 percent of low-income Californians are uninsured,

compared with 33 percent of low-income adults in Florida and 51 percent in Texas. Even before the

passage of the Affordable Care Act, both New York and California had established Medicaid

eligibility levels that were more generous than most states. And under the health reform law, both

states expanded eligibility for Medicaid up to 138 percent of poverty, while Florida and Texas did

not (Rasmussen et al., 2015).

Figure 10

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Economic Effects of Medicaid Non-Expansion States on Hospitals

America's rural hospitals are in crisis. Small practices and pediatricians are in danger of

going out of business. University of North Carolina's Rural Health Research Program tracks that

they closed ten hospitals in 2020, and Texas, Nebraska, Wisconsin, and Pennsylvania's rural

areas have more low-income families who cannot afford the care they need. Policymakers need

to do better to bridge this gap before the change takes place for the better. The disparity will be

seen through the states, including rural areas. Low Medicaid reimbursement rates to hospitals

and healthcare providers do not make Medicaid expansion enticing for states. Patients do not

really benefit from the expansion due to the care. An agenda for reform shows that in-hospital

death rates for surgical patients show variation in outcomes based on coverage.

The death rates of Medicare, Medicaid, and uninsured patients were 97% higher than patients

with private insurance. The average hospital length of stay of privately insured patients was 7.38

days, Medicare stayed 19%, and Medicaid stayed 42% longer. Even though the length of stay

was longer, the outcomes were worse. Medicaid patients cost, on average, more than 26%.

(Antos et al., 2015) Low reimbursement causing poor outcomes is one of the reasons that

patients are skeptical about Medicaid. Expanding Medicaid will allow more plans in the

marketplace, giving more options and lower costs overall. Medicaid reimburses physicians only

61 cents on the dollar (Antos et al., 2015), which makes physicians opt-out of taking Medicaid

insurances, making specialists and primary care physicians unreachable for the patients who

need it. Patients on Medicaid do not have much choice other than to use the emergency room for

their needs; this goes back to putting the burden of free care on the hospitals. Hospitals such as

Northside hospital in Georgia are constantly trying to be innovative in Revenue cycle practice.

Non-for-profit hospitals offer financial assistance as charity to the community and their patients

21

who are covered for a certain period during which they qualify. They can get their tests,

including x-rays, C.T. scans, MRI, Ultrasound, and labs done at little or no cost. Any of the

outpatient testing, procedures, some surgeries, and all services that the hospital covers can be

covered under the charity status. Patients that make too much can go as self-pay and get a special

self-pay rate of 75% discount. Chartis Center for Rural Health deems 2019 the worst year for

rural hospital closures, with 19 hospitals closing and one out of four hospitals show early

warning signs of closure (Scott, 2020). Chartis studies hospitals in rural areas that are in danger

of closing to see if they are in non-expansion states. Medicaid expansion states decrease the

likelihood of closure by 62%. Texas, Tennessee, Oklahoma, Georgia, Alabama, and

Missouri refused to expand Medicaid and have a 75% hospital closure rate (Scott, 2020).

Hospitals such as Northside hospital in Georgia are constantly trying to be innovative in Revenue

cycle practice. The hospital is not-for-profit and offers financial assistance as a charity to the

community and its patients. This was the patient covered for a certain period of which they can

qualify, and they can get their tests, including X-rays, CT scans, MRI, ultrasound, and labs done

at little or no cost. Any of the outpatient testing, procedures, some surgeries, and all services that

the hospital covers can be covered under the charity status. Patients that make too much can go

as self-pay and get a special self-pay rate of 75% discount. This leaves a disparity in health

outcomes to disadvantage populations. Policymakers need to find a way to bridge this gap to see

results. Hospitals and hospital associates continue to rally for Medicaid expansion due to their

diminishing resources. Resources that have already been exhausted due to the

Emergency Medical Treatment and Labor Act of 1986 (EMTALA) (Allen, 2018). The

Congressional Budget Office (CBO) suggests that Medicaid would add very little or no costs to

the states compared to what the states would bear if there were no health reform at all (Angeles,

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2012). Expanding Medicaid will ensure reimbursement for hospitals. CBO predicts that 17

million more people will be covered in expansion, reducing the state's costs for uncompensated

care and other programs alike. The federal government will pick up the bulk of the costs of

Medicaid expansion, which is favorable for states and for their residents in need of insurance

(Angeles, 2012). Federal law mandates in the ACA for nonprofit hospitals to increase

community benefits in exchange for their "lucrative" tax status. According to research, they are

still very stagnant in going so. Tax-exempt hospitals spent an average of 7.6% in 2010 of their

total spending on community benefits, while the total operating costs increased to 8.1% by 2014.

The bulk of this sending went toward non-reimbursed patient care such as charity. Boston

University professors test that Gary Young from Boston University says that this is not easy for

hospitals to do since their focus has been on treatment and not prevention (Connor, 2018).

Methodology

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This study is a qualitative analysis of archival data from peer-reviewed journal articles.

From 1992 through July 2021, four academic databases, PubMed, JSTOR, JAMA, and NEJM,

were searched to identify relevant literature, and 43 news articles, interviews, and official

government websites were searched for more recent data. The inclusion criteria was based on the

search keyword terms were "Affordable Care ACT, mandate, healthcare cost," "Expansion AND

States. In addition, search filters were added to refine the results. Exclusions were any articles

that didn't dive into the results of Medicaid non-expansion. Articles that were focused on specific

illness and disease were also omitted due to the title of the thesis. Search filter criteria were

English language, academic journal publications, peer-reviewed, and published in 1990 for

classic articles and 2014 through 2021 for more relevant data. JAMA database was used only for

a health policy subject because PubMed did not offer that subject filter. 57 articles were included

for analysis and 14 were excluded for analysis.

Figure 11

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Methodology Chart

PubMed JSTOR JAMA NEJM

Non-

Scholarly

Articles

Initial Search

1

Exclusion

Criteria Applied

0

Inclusion

Criteria Applied

1

Initial Search

0

Initial Search

12

Initial Search

57

Exclusion

Criteria Applied

0

Exclusion

Criteria Applied

0

Exclusion

Criteria Applied

0

Exclusion

Criteria Applied

14

Inclusion

Criteria Applied

12

Inclusion

Criteria Applied

43

Inclusion

Criteria Applied

0

Inclusion

Criteria Applied

1

Initial Search

1

Excluded for Analysis

14

Included for Analysis

57

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Findings/Analysis

Medicaid has been a source of official insurance for low-income children, parents, elderly, and

disabled individuals to improve health outcomes. Medicaid expansion with the Affordable Care

Act (ACA) authorized states to extend Medicaid levels for all adults with income up to 138

percent of Federal Poverty Level (FPL). Medicaid is the largest health insurer in the country with

66 million approximately. (Manatt, Phelps & Phillips, LLP. 2019). Medicaid was associated with

improved medical outcomes, such as access to care, higher preventative care, and screenings,

decreased hospital and Emergency utilization and decreased infant mortality rates. People were

more confident within their health care practices since the cost was not the biggest issue (Manatt,

Phelps & Phillips, LLP, 2019). Medicaid expansion in the remaining states would insure over 14

million people who are uninsured. Due to the current economic crisis due to the COVID

pandemic, people with no insurance are afraid to seek medical attention. In economic crisis,

people who have lost their jobs can still get coverage if Medicaid were expanded. This will

allow them the peace of mind to seek medical attention with chronic diseases such as diabetes,

hypertension, and heart disease (Schubel, 2020).

Positive Health Outcomes

Medicaid expansion gives peace of mind and body to citizens. ACA has improved

access to care and utilization of services among the low-income population. Improved access to

care and utilization have led to an increase in early diagnosis, which leads to better outcomes of

chronic disease. States that expanded Medicaid have seen improvements in access to medications

and

services for behavioral and mental health conditions (Antonisse et al., 2018).

A study in Maryland showed that a year after expansion, there was a small but statistical

26

difference in more emergent cases in the emergency room rather than using it as a primary care

facility. Another study showed a decline in the length of stay for Medicaid patients. There are

many studies showing positive self-reported outcomes of individuals who have had lifesaving

treatments and care that could not have afforded care prior to expansion. An Ohio study post-

expansion showed a decrease in medical debt since enrolling in Medicaid. Antonisse et al.,

2018).

States' Economics and Politics

Since the 2016 elections, "repeal and replace" bills have been a point of

contention in Congress. Though they are aimed at changing Medicaid and its details, they have

still kept Medicaid expansion in place. The replace and Repel bill would not repeal the ACA's

expansion of the Medicaid program, it will reduce the cost to the federal government. It is to

allow states to maintain the higher initial federal funding till 2020 (Flood et al, 2017). It will be

impossible and a threat to any party or group of people that will rescind coverage for over 12

million newly covered Medicaid beneficiaries since then. This has been the reason for the failure

of all "repeal and replace" bills.

States' residents pay over $3 trillion dollars in federal income taxes. The federal

the government keeps the money for federally funded activities and sends back funding to

the state governments through Medicaid and other programs. This process is

called "financial migration". In 2018, it was projected that 55 percent of all federal

assistance to state and local governments derived through the federal match program for

Medicaid (Allen, 2018). The states that have chosen not to expand Medicaid have

been primarily Republican governors and lawmakers. Kaiser Family Foundation (KFF) reports

studies positive budget savings, revenue gains, and overall economic growth. During FY 2010-

27

2015, the federal government paid 100% of the costs related to transportation, education, or

other state programs related to Medicaid expansion (Guth et al., 2020).

The goal of the Trump administration was to repeal the ACA, and it set out to cut expansion of

low-income adults and impose "rigid" caps on the federal government's Medicaid spending.

Despite Trump's determination to repeal the ACA, Congress rejected many of his proposals in

2017 (Center on Budget and Policy Priorities. 2020).

Trump's administration proposed rules in 2019 that aimed to make it hard for the states to

pay for their share of Medicaid costs. These rules can significantly change the costs and

coverages of Medicaid in the states. In 2019, a proposal to lower the poverty line would

cause millions of people to lose their coverage and receive less help from federal aid programs.

(Center on Budget and Policy Priorities. 2020). In 2018, Trump gave states the authority to pay

premiums for health coverage in the marketplace, knowing very well that higher premiums will

lower Medicaid participation. States were given full authority to take away coverage from low

income people who could not afford to pay their premiums (Center on Budget and Policy

Priorities. 2020). This causes more fear within the low-income population, causing them to flee

from any coverage and again turn to the emergency room for service.

American Rescue Plan Act

American Rescue Plan Act (ARP) is part of the COVID-19 relief package that became law

March 11, 2021. The ARP contains many provisions which increase coverage, expand benefits,

and adjust federal financing of Medicaid programs to states (Musumeci, 2021). In addition to the

already 90% federal funding, they can now get another 5% increase for two years. The new

incentive is available for the 12 states that have not expanded Medicaid, as well as Oklahoma

and Missouri, which are expected to expand Medicaid by July 21, 2021. An additional 10%

28

increase can be matched if the states incorporate more senior and people with disability

resources, which allow them to live and function in the community (Musumeci, 2021). The ARF

coverage provisions are:

1. Mandatory coverage of Covid-19 vaccines.

2. Option to extend post-partum coverage to 12 months.

3. Community cased mobile crisis intervention service.

4. Extension of 100% federal financing to Urban Indian and Native Hawaiian health

Systems.

5. Medicaid during the Covid-19 emergency period.

6. Covid-19 relief funds for rural provides. (Musumeci, 2021).

The ARF will affect all aspects of the state's economy, and federal funding provisions will

benefit the states' economies in many ways. The "Multiplier" effect on the economy of federal

Medicaid Revenue is seen in the figure below.

Figure 12

29

Findings and Conclusions of the ARP is Medicaid will increase federal revenue for the 14

states by $49 billion in 2022 and collectively will expand their economies by $350 billion

from 2022 to 2025. 1 million jobs will be created with the largest gain in Texas

(298,900), Florida (134,700), North Carolina (83,000), and Georgia (64,300)

(Ku & Brantley, 2021). Economics in neighboring states will increase because of

the buying power that the states have to buy medical supplies from each other.

Figure 13

Furthermore, the uncompensated care costs for the nation's uninsured averaged $42.4 billion,

a decrease from $62.8 billion between 2015 and 2017. While substantial, these costs significantly

declined following the expansion of the Affordable Care Act's coverage expansion.

30

However, with the rise in the number of uninsured since 2017, provider uncompensated care

costs associated with caring for the uninsured have likely increased. Between 2017 and 2019, the

number of uninsured grew by an estimated 1.5 million (Coughlin et al., 2021).

\

31

Policy Implications

Medicaid expansion that began in 2014 has increased health insurance coverage

and improved access to affordable healthcare. Medicaid has covered 11.9 million new

patients in expansion states. Non-elderly adults without insurance have decreased from

13.6% before expansion to now 8.1%. Center for American Progress estimates that

expanding Medicaid could save lives, additional early-stage cancer diagnoses, reduction

in uninsured opioid hospitalizations, decrease in bankruptcies, and savings to local

governments from healthy communities (West, 2018).

The ACA has helped millions of Americans gain insurance coverage, saved thousands of

lives, and strengthened the health care system. The law has been life-changing for people who

were previously uninsured, have lower-incomes, or have preexisting conditions, among other

groups. Yet, even as the ACA's historical accomplishments are celebrated, it is important to note

the high stakes of the dedication that the Trump administration and its allies have shown to

dismantling the ACA and reversing a decade of progress (Rapfogel et al., 2020). Eliminating the

individual mandate would cause relatively small increases in premiums but large declines in the

number of people insured. The relatively small effect on premiums suggests that the individual

market would remain stable even without the individual mandate, owing largely to the effects of

subsidies, which are structured to keep premiums low for eligible enrollees. However,

eliminating the individual mandate has a large effect on the total number of people with

insurance because it affects the decisions of people who have employer coverage, in addition to

those with individual market coverage (Eibner et al., 2014).

32

Figure 14

Congress must keep lowering Medicaid funding for states that refuse to adopt and implement the

ACA. Congressional Democrats and President Joe Biden have vowed to find a path to convince

the last 12 states — Alabama, Florida, Georgia, Kansas, Mississippi, Missouri, North Carolina,

South Carolina, South Dakota, Tennessee, Texas, and Wyoming — to expand eligibility or

directly extend affordable insurance options to their residents. Biden's COVID-19 relief package,

the American Rescue Plan, offered more federal money to states that opted into the expansion

(Luthra, 2021).

33

Conclusion

States that refuse to expand Medicaid wreak havoc on the insurance markets (Rapfogel, Calsyn,

et al., 2020). Without coverage, people cannot get both the preventive and curative care they

need. Rising uninsured rates during the COVID-19 pandemic would be particularly dire, as the

uninsured may not only risk their own lives by avoiding treatment but also unwittingly spread

the coronavirus without adequate and affordable care. The ACA is a lifeline for employees of

small businesses and the self-employed. Prior to the ACA, most uninsured workers were self-

employed or working at small businesses and had few affordable, comprehensive coverage

options. Since the ACA was enacted, the uninsured rate for small-business employees has

dropped by nearly 10 percentage points (Rapfogel, Calsyn, et al., 2020).

Insurance companies must now spend at least 80 percent of insurance premiums

on medical care and improvements. The ACA also aims to prevent insurers from making

unreasonable rate increases. Insurance coverage is not free by any means, but people now

have a wider range of coverage options. Preexisting conditions, such as cancer, made it

difficult for many people to get health insurance before the ACA. Most insurance

companies would not cover treatment for these conditions. They said this was because the

illness or injury occurred before you were covered by their plans (Roland, 2015).

Under the ACA, you cannot be denied coverage because of a preexisting health

problem. The ACA covers many screenings and preventive services. These usually have

low copays or deductibles. The hope is that if you are proactive in your healthcare, you

can avoid or delay major health problems later. Healthier consumers will lead to lower

costs over time. For example, a diabetes screening and early treatment may help prevent

costly and debilitating treatment later.

34

"The ACA is going to help all Americans have higher quality and less costly healthcare in the

decades to come," says Dr. Christopher Lillis, an internist in Virginia and a member of Doctors

for America (Roland, 2015).

ACA has many aspects that will enhance the health outcomes of Americans and improve

U.S. healthcare. States must adopt this expansion and allow the marketplace to work itself

through allowing for better prices of medical supplies, medical coverage, and prescriptions. The

states will continue to flourish as they are able to be funded for several other programs as a stem

of the expansion. The states will not be responsible for the bulk of the costs as originally thought

by the lawmakers and stakeholders alike.

35

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44

Appendix: List of Figures

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45

Ku, L., & Brantley, E. (2021, May 20). Economic and Employment Effects of Medicaid

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