Medicaid Expansion


Time: D H M S

h/t to Annette Prentice for the heads up on this. Via Michigan Public Radio:

State Senate introduces bill to add work requirements to Medicaid

The bill would require able-bodied adults to work or be in school for 30 hours a week in order to receive Medicaid.

Some lawmakers in Lansing want people to work to get Medicaid. The Senate introduced a bill Thursday. It would add work requirements to the Medical Assistance Program, or Medicaid.

...If passed, able-bodied adults would be required to work or continue school for 30 hours per week as a condition of receiving medical assistance.

There’s a similar bill in the state House. It’s been waiting for a committee hearing since December.

Opponents say there shouldn’t be more restrictions on health care – which they say is a human right.

Nearly three years ago, there was a big report about a bunch of Republican Governors of states which hadn't expanded Medicaid under the Affordable Care Act who claimed that they were willing to do so, but only if a work requirement was part of the deal:

In nearly a dozen Republican-dominated states, either the governor or conservative legislators are seeking to add work requirements to Obamacare Medicaid expansion, much like an earlier generation pushed for welfare to work.

The move presents a politically acceptable way for conservative states to accept the billions of federal dollars available under Obamacare, bringing health care coverage to millions of low-income people. But to the Obama administration, a work requirement is a non-starter, an unacceptable ideological shift in the 50-year-old Medicaid program and a break with the Affordable Care Act’s mission of expanding health care coverage to all Americans. The Health and Human Services Department has rejected all requests by states to tie Medicaid to work.

Last November, along with voting to keep a Democrat in the Governor's office, Virginia voters also swept a huge wave of Democrats into office in the state legislature. They didn’t quite take a majority, but they came within a single vote of getting a 50-50 tie in the state Assembly. Instead, they have a two-vote shortfall (51-49), matching the same two-vote shortfall (21-19) in the state Senate.

New Governor Ralph Northam has solidly promised to finally push through ACA Medicaid expansion for 400,000 Virginians, but those two-vote margins have made doing so incredibly frustrating. Fortunately, it looks like the dam may have finally been broken:

A prominent Republican state legislator from southwest Virginia announced his support Thursday for expanding Medicaid, an about-face that could make it easier for other rural conservatives to get on board after four years of steadfast opposition.


From the Cabinet Meeting scene in the comedy "Dave":

DAVE: Now the Commerce Department..,

SECRETARY OF COMMERCE (sitting erect): Yes, Mr. President?

DAVE (from a card): You're spending forty-seven million dollars on an ad campaign to... (reading) 'Boost consumer confidence in the American auto industry.'

SECRETARY OF COMMERCE: Um...yes,'s designed to bolster individual confidence in a previous domestic automotive purchase.

DAVE: So we're spending forty-seven million dollars so someone can feel better about a car they've already bought?

SECRETARY OF COMMERCE: Yes, sir, but I wouldn't characterize it that way...

DAVE (indignant): Well I'm sure that's really important, but I don't want to tell some eight- year-old kid he's got to sleep in the street because we want people to feel better about their cars. (beat) Do you want to tell him that?

SECRETARY OF COMMERCE (quietly): No sir...(looks at TV cameras) sir, I sure don't.

I don't have much to add here. This is sad and depressing to watch unfold.

Indiana Adds Work Requirement To Medicaid, Will Block Coverage If Paperwork Is Late

Indiana on Friday became the second state to win federal approval to add a work requirement for adult Medicaid recipients who gained coverage under the Affordable Care Act. A less debated provision in the state's new plan could lead to tens of thousands of people losing coverage if they fail to complete paperwork documenting their eligibility for the program.

The federal approval was announced by Health and Human Services Secretary Alex Azar in Indianapolis.

Medicaid participants who fail to promptly submit paperwork showing they still qualify for the program will be locked out of enrollment for three months, according to updated rules.

Except he's not threatening to shoot a dog; he's threatening the lives of nearly half a million of his constituents.

Bevin issues ultimatum: If courts block Medicaid plan, half million Kentuckians will lose care

Gov. Matt Bevin has issued an executive order that would strip Medicaid coverage from nearly half a million Kentuckians should his proposed overhaul of the federal-state health plan be struck down in court.

No one has filed a legal challenge to Bevin's changes to Kentucky's Medicaid program that federal authorities approved Friday.

But several advocacy groups have said some of the changes — such as requiring some "able-bodied" adults to work or volunteer at least 20 hours a week — likely will be challenged in court because they violate federal law that establishes Medicaid purely as a health program and does not authorize work requirements.

With the big news this week about CMS giving work requirements the green light and Kentucky immediately jumping all over it, I decided to look up a few data points from some expansion states which don't include a work requirement for the heck of it:


  • As of January 8th, 2018, Michigan had 669,362 adults enrolled in the "Healthy Michigan" program (aka, ACA Medicaid expansion), or over 6.7% of the total population.
  • Men make up slightly more enrollees than women (51% to 49%)
  • Enrollees are spread fairly evenly by age brackets (19-24, 25-34, 35-44, 45-54 and 55-64)
  • Around 80% of MI expansion enrollees earn less than 100% of the federal poverty line; the other 20% earn between 100-138% FPL.


  • As of January 8th, 2018, Louisiana had 457,178 adults enrolled in Medicaid expansion (nearly 9.8% of the population)
  • Women make up 62% of enrollees

As of December 4, 2017...

*UPDATE: Some have accused me of hyperbole in the headline because a) it's a "state-approved health or financial literacy" course, not a "can you read" test and b) because it would only be required if they're unable to meet the requirements in other ways. I guess I can see their point, but it strikes me as splitting hairs:

First, "literacy course" was their wording, not mine (I guess there's a distinction between "completeing a course" and "passing a test"?).

Second, there doesn't appear to be any real description of the "courses" in question--how long it is, what the criteria for measuring "completion" is, who would be conducting the course, whether you'd have to attend classes in person (vs doing so online?), how many sessions there'd be and so forth. Here's the description as laid out in the waiver request itself:

I used to track the monthly Medicaid/CHIP enrollment reports issued by CMS, watching as the numbers rose dramatically thanks to ACA Medicaid expansion.

I pretty much stopped doing that about a year ago, however, since the expansion numbers have mostly petered out. ACA Medicaid expansion actually has continued to climb a bit more since January, and is likely somewhere around 16 million people as of now, but it's also been partly cancelled out by a slight drop in standard Medicaid enrollment as the economy has continued to improve in general. In short, there's little reason to keep writing the same update every month.

*(OK, Maine is a lock...except that GOP Gov. LePage is apparently still being an utter jackass about implementing it, while Virginia is still kind of iffy...see below...)

UPDATE 11/8/17: Maine voters approve Medicaid expansion

Maine voters on Tuesday decided to expand Medicaid to cover more low-income adults, becoming the first state to do so through a referendum.

Support for the ballot measure was up by more than 18 points with 64 percent of precincts reporting about 10 p.m. when it was called by NBC affiliate WCSH and The Associated Press.

The results in Maine, one of 19 states that rejected Medicaid expansion under the Affordable Care Act, comes as other Republican-led states like Utah and Idaho eye similar ballot measures.

Advocates of Medicaid expansion in Maine successfully petitioned the state to include a question on this year’s ballot following several failed legislative efforts to expand the program.

Here's the latest enrollment data from the Louisiana Department of Health.

I've embedded screen shots below, but there's various interactive stuff you can do at the site itself; LA did a very nice job, I'd love it if every state put up a similar "dashboard" style website.

In short:

  • 434,594 Louisianans enrolled in Medicaid via ACA expansion
  • 126,229 have received preventative care
  • 22,058 women have received breast cancer screenings
    • 225 women have been diagnosed with breast cancer as a result of ACA Medicaid expansion
  • 13,994 adults have received a colon cancer screening
    • 4,337 have averted colon cancer by having polyps removed
    • 199 have been diagnosed with colon cancer thanks to ACA Medicaid expansion
  • 3,774 have been diagnosed with diabetes
  • 9,575 have been diagnosed with hypertension
  • 32,912 are receiving outpatient mental health services
  • 6,025 are receiving inpatient mental health services
  • 5,559 are receiving outpatient substance abuse services
  • 6,026 are receiving residential substance abuse services

Not the highest-profile ACA/healthcare story in the world, but Wyoming almost never makes the news, and this is especially noteworthy given the state, the Governor and the GOP having total control over the federal government:

As health care debate simmers, Mead laments lack of Medicaid expansion in Wyoming

Gov. Matt Mead lamented the $100 million that Wyoming left on the table by choosing not to expand Medicaid, and he expressed concern for the state’s hospitals while discussing health care with the Star-Tribune recently.

Mead echoed some of the fears that many Wyoming hospital officials have expressed for months: that congressional proposals to overhaul the health care system may have negative effects on facilities here and that the state has suffered because it chose not to allow more people to qualify for Medicaid.

“The idea that we did not accept Medicaid expansion and things are going to be good just hasn’t turned out,” he said.

As regular readers know, I've been a bit obsessive about tracking down and breaking out ACA Medicaid expansion enrollee numbers. This is more difficult than it sounds, because most Medicaid reports lump expansion enrollees in with the other ~58 million or so Medicaid enrollees; only a handful of states issue separate reports of the expansion-specific population on a regular basis.

Back in late November, I cobbled together the data as best as I could and came up with a total of roughly 11.3 million people nationally. However, that included a lot of 2-year old data and rough estimates.

A couple of weeks later, I stumbled upon a detailed analysis from an anti-ACA financial watchdog organization, the Foundation for Government Accountability, which provided hard numbers and confirmable data source links which included more recent numbers for many states. This brought the total up to over 12.3 million.

Of the 31 states which have expanded Medicaid under the Affordable Care Act, only a handful issue regular monthly or weekly enrollment reports.

Back on February 28th I noted that ACA Medicaid expansion enrollment across three states (Michigan, Louisiana and Pennsylvania) had grown by about 35,000 people since mid-January, to 667K, 406K and 716K people respectively.

Today, a month later, I decided to take another look at all three states, along with Minnesota (which I forgot to check last month). Sure enough, enrollment has continued to grow in all four, albeit at a slower pace:

Over the past month or so, I've been tallying up the number of people who would lose their healthcare coverage if and when the GOP actually does proceed with repealing the Affordable Care Act, breaking the totals out by both County and Congressional District in every state.

While this project has received high praise as a useful resource, one problem with it is that the numbers aren't static--between the high churn rate of the individual market and Medicaid, as well as the fact there's no limited enrollment period for Medicaid (you can sign up year-round), the enrollment figures are constantly changing.

Case in point: As of the beginning of January, roughly 640,000 Michiganders were enrolled in "Healthy Michigan", our name for ACA Medicaid expansion. By the end of January, that number had increased to just over 646,000.