Report Highlights Medicaid Growth in Non-Expansion States

A new report on Medicaid highlights how the Affordable Care Act (ACA) helped millions of poor Americans gain coverage that many should have had anyway. However, funds for the people who helped make this happen—the navigators deployed under the healthcare law—have been largely cut by the Trump administration.

Last week, the consultant PwC presented its 2017 report, “The Complicated State of Medicaid in the United States,” which showed that overall, the phenomenal growth of Medicaid seen since 2013 had stalled in the past year, as no new states took up Medicaid expansion. With 75 million enrollees of diverse backgrounds, ages, and needs, Medicaid proved to be complicated politically, and “will remain in the spotlight for the foreseeable future, dominating the headlines and permeating the nation’s debate,” report author Ari Gottlieb wrote.

Tucked within the PwC report, however, is a point that is often overlooked, especially within the context of navigator funding: Medicaid expansion since 2013 has not occurred only within the population formally expanded under the ACA—the working poor who earn between 100% and 138% of the federal poverty level. The ACA also created a “no wrong door” policy for enrolling people who met the criteria for traditional Medicaid. This meant states could no longer erect barriers to benefits for people who were eligible—the same process applied everywhere.

The presence of navigators, coupled with increased publicity each year around open enrollment put millions of poor Americans in front of navigators, who would often determine that a person was eligible for traditional Medicaid.

The PwC report noted: “Even within expansion states, a significant portion of the growth in Medicaid enrollment has come from outside of the expansion population,” noting that of the 81,000 added to Montana’s rolls, 43,000 were “legacy” enrollees. In Colorado, 375,000 of the 675,000 new enrollees were added to traditional Medicaid.

The bigger surprises occurred in states that did not expand Medicaid but saw surges anyway: The PwC report notes that in Texas, the Medicaid rolls have jumped 26%; in Florida, 25%; and in Idaho, 18%. Overall Medicaid growth in non-expansion states totals 2.6 million people, compared with 15.2 million in expansion states, according to PwC.

“This phenomenon suggests that a number of individuals are seeking health coverage, often with the support of an enrollment counselor or navigator, and realizing they are eligible for traditional Medicaid categories,” the report notes.

Last month, HHS announced it would cut the navigator program by 41% and cut advertising funds from $100 million to $10 million. It has called the outreach programs a waste of taxpayer funds, and many health plans have stepped up their own outreach efforts to fill the void during ACA open enrollment.

Meanwhile, a little-noticed provision of a proposed CMS rule would take away an ACA requirement that at least some navigators be funded by consumer-oriented groups. It is not clear if navigators under the proposed rule would have the same ability or incentive—or any mandate—to enroll consumers in traditional Medicaid if that is the appropriate coverage.

The PwC report notes the quiet growth of managed care within the Medicaid population. While no new states have proposed conversions to this form of Medicaid management, those already using managed care have increased the share of the population under its umbrella. “Today, 12 states have at least 90% of Medicaid populations covered by private plans, up from 9 last year, and only 4 in 2013,” the report states; while 5 have 99% of beneficiaries in a private plan, up from 2 last year. Major expansions in managed care took place in West Virginia, Missouri, and Nevada.