Introduction
In an effort to reduce the number of US citizens that are not insured, the Affordable Care Act (ACA) provided for a mandatory Medicaid expansion program. The aim was to expand eligibility of low-income citizens to medical insurance. Under the ACA, the Medicaid expansion was geared at ensuring that adults earning below $16,242 per year in 2015 were eligible for Medicaid in all states (Rudowitz, Artiga & Musumeci, 2015). However, the Supreme Court ruling on the constitutionality of the Act prevented the mandatory expansion. Despite the ruling, 24 of the 29 states are in the process of the implementing the expansion as provided forth by the law. Five states have sought approval through waivers provided in Section 1115 (Rudowitz et al., 2015).
Other states such as New Hampshire requested CMS for approval to use an alternative model for premiums.
In accordance with Section 1115, five states are approved for the expansion of the Medicaid. The approved states include Iowa, Pennsylvania, Arkansas, Michigan and Indiana. The ACA allows the states to expand the Medicaid without adhering to federal rules. However, the states remain eligible for receiving funds for qualified adults.
Under the ACA, the federal government pays 100% for costs of the new eligible adults covering years 2014 to 2016. The federal government payment is to reduce to 90% in 2020 and the subsequent years (Rudowitz et al., 2015). The waivers approved for the states differ. For instance, state of Indiana received unique waiver approval. The approval prohibited the state from retroactive eligibility and allowed charging of high-cost sharing of non-emergency services. In other states, the waiver proposals are in developmental stages or pending approvals. Examples of states exploring alternatives are Tennessee and Utah.
Evaluation of Perspectives
In order to allow medical coverage for many people, the Medicaid expansion stakeholders have to establish a balance between the waiver applications of states. The Supreme Court ruling provided that states were at liberty to participate in the program or explore alternatives that were politically viable (Rudowitz et al., 2015). Section 1115 waivers provided a viewpoint in which states opted to test the approaches for the Medicaid program. The implication of the ruling was that states were at liberty to explore other options for expanding Medicaid. However, the decision did not abolish all the provisions provided in the ACA. Section 1115 waiver provides for alternatives that some states have explored by applying for approvals to implement the program in a political viable manner acceptable to the states.
The idea of the pilot projects raises concern about the sustainability of the funding process and feasibility of the projects. For instance, before the ACA, adults without children were ineligible for coverage based on disability or age status (Rudowitz et al., 2015). The federal law did not provide funds to match the funds for the ineligible adults irrespective of the low incomes. The limited coverage options for such adults were remedied by states applying Section 1115 waivers. Comparing the earlier situation before the ACA and now, the question of political viability of the Medicaid is not certain. It points to a perspective where political willpower is based on the federal funds but not the needs of the citizens. For instance, under the ACA, states apply for approval under Section 1115 and implement the Medicaid expansion without strictly following the federal rules.
The approvals make the states eligible to receive federal government funding (Rudowitz et al., 2015). The dispensation of expansion based on federal funding under the waiver approvals entices the states to the program and hence extensive coverage. However, it is worth noting that different states have applied for different approvals. For example, the state of Indiana received an approval not to provide ‘retroactive eligibility’. The future of the program could be short term and likely to be withdrawn in case the federal government funds matching the eligible adults reduce significantly.
The implementation of Medicaid expansion is based on the political viability of the states. The differing applications processes in the states compromise the comprehensive coverage for low-income citizens. In addition, the approval process does not include the inputs from the public. The lack of public participation negates the transparency and public engagement in the waiver approval process. Even though CMS has ensured that that there are common themes that guide the approval process, the transparency issues raise concerns on whether the expansion is centered on individual wellbeing or a purely political process. For instance, CMS waiver approval allows the states to charge premiums for adults with income range of 100 to 138% FPL. The waiver is unlike the federal law provisions that do not permit charging of premiums for adults with incomes below 150% FPL ($17,655 per year for individual in 2015). However, CMS has denied approvals for premiums for people with 100% FPL in the states where eligibility is based on payment (Rudowitz et al., 2015).
The primary goal of Section 1115 waivers is to increase Medicaid coverage. Many states are poised to use exemptions for the Medicaid expansion. States have different issues on the Medicaid expansion. The differences make the design of the waivers becomes very complicated. Thus, there is the need for extensive research and demonstrations of the effectiveness of the waivers. Evaluations of the states that have already implemented the waivers will be critical in the identification of the way forward for effective Medicaid coverage.
Reference
Rudowitz, R., Artiga, S. & Musumeci, M. (2015). The ACA and Medicaid expansion waivers. New York: Kaiser Commission on Medicaid and the Uninsured, Kaiser Family Foundation.