The ACA and Medicaid: Where You Live Matters

What a difference a state makes. Ask my friend, a laborer whom I’ll call John.

Some months ago, John realized that a cyst-like lump on his trunk was growing and becoming bothersome. He has no health insurance so he paid out-of-pocket for a physician to examine it. Tests were negative and he was told it was “probably nothing.” The lump continued to grow and became uncomfortable, but John couldn’t afford to have it removed. When he shared this information with me, I told him that he probably qualified for Medicaid in New York State. He looked into it and discovered that he did. He signed up for it and went to a surgeon to remove the lump, now the size of a baseball and causing him increasing discomfort. After the test results came back, the surgeon told John that it was a malignant tumor. Fortunately, there is no evidence of metastasis, and John can proceed with the necessary treatments under Medicaid.

This story would likely have a very different outcome if John lived in Florida, Maine, Idaho, Kentucky or another of the 26 states that have not signed up to expand their Medicaid programs, as called for under the Affordable Care Act (ACA). As of September 2013, only 24 states plus the District of Columbia have committed to expanding their Medicaid programs.

How can this be? The 2012 Supreme Court’s review of the constitutionality of the ACA supported the federal government’s right to require that individuals purchase health insurance (the “individual mandate”), but it struck down a requirement that states expand their Medicaid programs to all adults under the age of 65 years who earn 138% or less of the federal poverty level (FPL) (in 2013, the poverty level is $15,626 for an individual and $32,499 for a family of four). States that failed to do so were to have forfeited their existing Medicaid programs that covered mostly women and children under the FPL. (Children ages 6 to 18 who fall at or under the FPL were covered by the existing Medicaid program; under the ACA, they are now covered up to 138% of the FPL under a separate section of the law that is untouched by the Supreme Court ruling.)

After the Supreme Court ruling, expansion of Medicaid became an option for states rather than a requirement. Why would states not want to do this? One reason is that it would cost the states some additional monies, though not very much. From 2014 to 2016, the federal government would pay 100% of the cost of the expansion. After 2016, it would pay 90% of the costs and the states would pay 10%. Seems like a deal for the states, but politics enters into the equation. The majority of the states opting out of the expansion are “red” states where the governor and/or legislature oppose “Obamacare”. Many of these states are at the bottom of the rankings of key health indicators.

I thought John would have qualified for the new state health insurance exchange that New York is implementing. The exchange will subsidize the cost of insurance for people in all states from 133% of the FPL (139% for people living in states that have adopted the Medicaid expansion) to 400% FPL. But John’s income is under the 139% in New York State, so he qualified for Medicaid.

John may be living a much longer life because New York opted to expand its Medicaid program. What about the unfortunate folks who live in states that didn’t opt in?

Diana J. Mason, PhD, RN, FAAN, Rudin Professor of Nursing