Medicaid gets Affordable Care Act bump in Pennsylvania

Enrollment here up 18K thanks to ‘woodwork’ effect

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Pennsylvania’s Medicaid enrollment is up by more than 18,000 people since the Oct. 1 launch of the Affordable Care Act’s online health plan marketplaces.

The state's enrollment bump in the program for low-income families and individuals is small, though it coincides with larger jumps being experienced in other Republican-led states. Supporters of the ACA are crediting the 2010 federal health care overhaul with encouraging more uninsured to examine their health coverage options. Subsequently they discover that they were already eligible for state-funded insurance programs.

It’s called the “woodwork” effect — people who may have been eligible for Medicaid or related children’s programs all along only learned of their eligibility during the six-month push to sign Americans up for health insurance.

In other words, they “came out of the woodwork.”

“We do have some indications that enrollment in Medicaid is going up, in even states that did not choose to implement the Medicaid expansion,” said Julie Sonier, deputy director of the State Health Access Data Assistance Center at the University of Minnesota. “That is something that was widely expected.”

The effect can be viewed both positively and negatively. It’s a positive for health overhaul advocates. But for those who were against “Obamacare” to begin with, it’s a case study in unintended consequences since new enrollees will mean new expenses for the state.

Prior to the passage of the Affordable Care Act, about 3.8 percent of the U.S. population — or 9.1 million people — under the age of 65 were eligible for Medicaid coverage but weren’t enrolled. Medicaid is a state-operated health insurance program for the poor and disabled, financed jointly by states and the federal government.

In states that expanded eligibility for their Medicaid programs to include all people and families making up to 138 percent of the federal poverty line — something encouraged as part of the ACA — Medicaid enrollment jumped more dramatically. Whereas Medicaid used to be a targeted program aimed at the most vulnerable segments of the needy population, the expanded version uses only household income as its determining guideline for eligibility.

As the result of a 2012 U.S. Supreme Court ruling, the expansion of state Medicaid programs is voluntary, not mandatory, as the ACA had envisioned. So while 26 states expanded Medicaid eligibility, using billions in federal money to pay for the health care of new enrollees, 24 states declined to do so. Pennsylvania is among them.

In the states that declined expansion, enrollment gains in Medicaid represent spillover from the ACA sign-up campaign.

“All of the news media focus on the health insurance exchanges” and the so-called individual mandate embedded into the Affordable Care Act helped drive increased awareness of health care options, Ms. Sonier said. In many cases, people tried to sign up for an individual plan on the federal or state exchange, only to be steered to Medicaid.

In total, U.S. enrollment in Medicaid has increased by 3 million people since the Oct. 1 launch of Healthcare.gov, to more than 61 million, according to early federal estimates.

Pennsylvania, for its part, says that assessing the impact of the ACA isn’t as simple as comparing September 2013 Medicaid enrollment to today’s numbers.

“The dramatic economic improvement over the last 18 months has made identifying the increase in enrollment due to ACA very difficult,” said Kait Gillis, spokeswoman with the state Department of Public Welfare, by email. The state’s unemployment rate is down to 6.2 percent in Pennsylvania, meaning the “likelihood of individuals needing Medicaid coverage certainly decreases.”

On the other hand, there are more people on Medicaid now than there were in 2008, the last time the unemployment rate was this low, Ms. Gillis said. “Medicaid is covering around 200,000 more people, in similar economic conditions.”

Regardless of whether the additional 18,000 Medicaid enrollees since October reflects an ACA-fueled bump or a natural fluctuation, it’s a small increase. One in 6 Pennsylvanians — about 2.21 million — are now enrolled in Medicaid. So an increase of 18,500 enrollees is less than 1 percent of the state’s total.

By contrast, Montana, Idaho and Florida — all nonexpansion stares — saw their Medicaid enrollments grow by 7 and 8 percent.

And other states saw Medicaid enrollment decline over the last six months, a sign that the “woodwork” effect isn't working everywhere.

Why was Pennsylvania’s increase so small? Partly because the state does such a good job of signing up those eligible in the first place. In 2011, according to the Robert Wood Johnson Foundation, Pennsylvania signed up 83 percent of adults eligible for Medicaid, which is fourth-best among the states, third-best not counting Massachusetts, which mandates health insurance coverage for all residents.

Compare that to lower-end states: Arizona, Nevada, Georgia, Oklahoma, South Carolina and Texas had all signed up less than two-thirds of the Medicaid-eligible, with Arizona at the bottom of the pack with 58.6 percent.

Still, an 83 percent success rate leaves nearly 1 in 5 eligible Pennsylvanians not enrolled in Medicaid, and a Gallup poll out Wednesday suggests that the states that more fully embraced the ACA — by building their own online insurance exchanges and by using federal funds to expand Medicaid — saw their rate of uninsured drop at a faster clip than states that did neither.

A Tuesday report from the Urban Institute said the same thing: States that expanded Medicaid saw their uninsured rate drop 4 percent, and states that didn’t expand saw a drop of 1.5 percent.

While Pennsylvania didn’t expand its Medicaid program in time for the January 2014 launch date, Republican Gov. Tom Corbett has proposed a Medicaid overhaul that would use the promised federal subsidies to help the uninsured buy their own private policies through commercial carriers. His “Healthy PA” plan has not yet received federal approval.


Bill Toland: btoland@post-gazette.com or 412-263-2625.

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