By Adam Sonfield
Senior Public Policy Associate
Guttmacher Institute
Washington, DC
The year 2015 is shaping up to be another big one for the joint federal-state Medicaid program. It is the second year of the Affordable Care Act’s (ACA’s) broad expansion of Medicaid to individuals below 138% of the federal poverty level. Medicaid enrollment surged in 2014, which helped to drive down uninsurance nationwide. By October 2014, 68.5 million individuals were enrolled in Medicaid, an increase of 9.7 million, or 17%, from the average monthly enrollment in July to that of September 2013.1 That enrollment is in addition to the 950,000-person increase in enrollment among six states and the District of Columbia that had chosen to expand Medicaid prior to 2014.
This impact, which is greater than that from the new “marketplaces” for private insurance, is all the more impressive because the ACA’s Medicaid expansion had been hobbled by the U.S. Supreme Court’s 2012 ruling that converted it from a federal requirement to a state option. Twenty-seven states and the District of Columbia had implemented a Medicaid expansion by January 2015.2 Those states accounted for most of the enrollment increase in 2014, and enrollment in expansion states rose by 24%.1 Enrollment increased by 7% in states that had not yet expanded, which most likely was driven by new ACA requirements to streamline the enrollment process and by heightened awareness about Medicaid among those eligible.
Medicaid’s importance can be expected to grow further in 2015. Policymakers have shifted their focus from campaigning to governing. Expanding Medicaid is a major priority in several states. Republican governors in Indiana, Tennessee, Utah, and Wyoming are in discussions with the Centers for Medicare and Medicaid Services (CMS), and the independent governor of Alaska and Democratic governors in Montana and Virginia also are proponents of expansion.2
Arriving at a proposal that will satisfy CMS and conservative state legislators will be a daunting challenge in at least some of these states. Yet, Medicaid’s momentum appears to be building, not only because of mounting evidence about the potential benefits for enrollees, but also because of pragmatic fiscal arguments, such as the vast amount of federal dollars being left on the table.
This news is all good for low-income Americans, for whom Medicaid is often the only path to affordable health insurance. These new enrollees are particularly likely to be young and unmarried, and therefore at heightened risk of unintended pregnancy. Luckily for them, Medicaid’s coverage of family planning services is strong, with federal law requiring all states to cover this care without any patient cost-sharing and providing for enhanced federal reimbursement to states as an incentive to cover the broadest possible array of methods and services.
These protections have translated into access to care. Even before the recent expansions, Medicaid was the fulcrum for publicly supported family planning in the United States, which accounts for three-quarters of all public dollars spent on those services.3 It is also central to maternity care. Notably, Medicaid pays for half of all U.S. births, including two-thirds of unplanned births.4 As Medicaid enrollment expands, these figures seem all but certain to continue rising.
Because of the ACA’s many changes to Medicaid, and because of the ever-increasing role of private-sector health plans in providing coverage for Medicaid enrollees, CMS has announced that it will be overhauling key Medicaid managed care regulations in 2015. That overhaul provides an opportunity for CMS to further bolster Medicaid’s protections for family planning patients and providers.
Family planning advocacy groups, including my organization, the Guttmacher Institute, have called upon CMS to do the following:
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clarify and enhance the obligations of states and health plans to cover the full range of family planning methods and services, without cost-sharing or other restrictions, such as prior authorization or inappropriate quantity limits;
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to respect patients’ confidentiality, paying particular attention to agency and plan communications about service utilization;
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to facilitate enrollees’ access to qualified providers, in-network and out-of-network;
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to ensure that patients have access to the full range of information and care, even if specific providers or health plans have religious objections.
In all of these areas, states and plans should improve communication with patients about their rights, and the federal and state governments should step up oversight and enforcement.
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CMS. Medicaid & CHIP: October 2014 Monthly Applications, Eligibility Determinations and Enrollment Report. Accessed at http://bit.ly/1zgyLQg.
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Kaiser Family Foundation. State Health Facts: Status of State Action on the Medicaid Expansion Decision. Accessed at http://bit.ly/1bs7xwY.
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Sonfield A, Gold RB. Public Funding for Family Planning, Sterilization and Abortion Services, FY 1980–2010. Accessed at http://bit.ly/1B5ErzW.
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Sonfield A, Kost K. Public Costs from Unintended Pregnancies and the Role of Public Insurance Programs in Paying for Pregnancy and Infant Care: Estimates for 2008. Accessed at http://bit.ly/1ITNPKK.
