There are two broad factors that indicate how many people have access to any Medicaid expansion. Obviously, the first factor is eligibility. States that don’t expand Medicaid won’t cover broad swaths of adults – about 5.4 million will get left out of Medicaid and not be eligible for subsidies. I might be one of them, at least temporarily.
That might seem like game over, but it’s not the whole story.
First, over time, political coalitions, institutional pressures, and flexibility on the part of HHS will likely shift a few more states in the Medicaid expansion (I’m looking at Maine, Montana, Missouri, and Virginia as potential short to medium-term examples).
This doesn’t help in states like Texas, or the usual suspects in Alabama and Mississippi, which seem hopeless when it comes to any chance of expanding Medicaid in the near or medium term. Millions of adults, disproportionately minority (of course), will be left out of insurance coverage.
But the eligibility is only part of the story. The second factor that helps gain access to services is the ease of with potential beneficiaries can apply. And the ACA helps ease this process considerably.
Currently, Medicaid utilization varies greatly by state. Some states actively try to make sure that all eligible get services, while some states make the application process as difficult as possible to keep enrollment (and costs) down through making applicants submit to multiple in-person interviews, kicking people out of the program for making trivial mistakes. In states like Texas, this means that hundreds of thousands of people who are eligible for Medicaid aren’t enrolled.
The ACA contains a number of federally required administrative changes to the Medicaid application process that weren’t touched by the Supreme Court’s decision to make Medicaid optional. The changes will generally streamline the process for enrollees and can be summarized as follows:
1. All states must allow registrants to apply through phone, online, in person, or mail
2. All state must maximize the use of electronic verification of eligibility to speed applications
3. All states must use a simple form of eligibility calculation based on a recipient’s Modified Gross Adjusted Income
4. All states must allow applicants to apply for Medicaid through the state health exchanges
5. States are encouraged to use a single form for applications for SNAP (food stamps), SCHIP (Children’s health) and Medicaid.
True, the states that reject the Medicaid expansion are also more likely to throw up road blocks to helping people enroll for the exchanges, by blocking access of navigators, for example. However, federal standards that simplify the application process across states will on net ease the access and increase enrollment.
Better administrative procedures aren’t a cure all. According to Kaiser’s numbers, 8.4 million people won’t be covered under the Medicaid expansion in the foreseeable future in states that opted out, thanks to the Supreme Court’s decision. (As I mentioned earlier, about 5.1 million won't be eligible for the subsidies, on the exchanges, while the rest will at least have those).
But if Kaiser’s analysis is right, standardizing and easing application procedure across the board will significantly increase enrollees – by roughly 2 million people across the states that haven’t yet accepted the Medicaid expansion (more than 500,000 in Texas alone).
That's one heck of a silver lining.