Continuing on with my 'drill-down' study of the Senate Health Reform Bill; today we'll look at a groundbreaking change for Medicaid that seems to have received little notice.
When it comes to Medicaid reform, most commentators only ever muster up one sentence: 'incomes below 133% FPL will receive expanded Medicaid', usually spoken in the context of insurance premium subsidies. That is a correct statement, but it belies the enormity of that change.
Medicaid, as it now stands, is a mess. It was designed to be a safety net of the very last resort. Eligibility varies greatly from state to state, and it's usually a hodge podge of conditions. Let's take California for a typical example. Here are the eligibility requirements:
http://www.dhcs.ca.gov/...
If you are enrolled in one of the following programs, you can get Medi-Cal:
SSI/SSP
CalWorks (AFDC)
Refugee Assistance
Foster Care or Adoption Assistance Program
In-Home Supportive Services (IHSS)
You can also get Medi-Cal if you are:
65 or older
Blind
Disabled
Under 21
Pregnant
In a skilled nursing or intermediate care home
On refugee status for a limited time, depending how long you have been in the United States
A parent or caretaker relative or a child under 21 if:
The child's parent is deceased or doesn't live with the child, or
The child's parent is incapacitated, or
The child's parent is under employed or unemployed
Have been screened for breast and/or cervical cancer (Breast and Cervical Cancer Treatment Program)
Other states' eligibility can be gleaned here:
http://www.statehealthfacts.kff.org/...
Right off the bat, you'll notice that if you are an adult without dependent chlidren, you are S.O.L. regardless of how poor you are. Medicaid is primarily targeted at families with children. Woe to you for not breeding. For families with kids, there is no clear income requirement; but you do have to qualify for Calworks (AKA TANF, formerly known as AFDC until the Clinton Welfare Reform) first before you can qualify for Medicaid. Calworks has an income limit of approximately 70% FPL:
http://www.disabilitybenefits101.org...
And Calworks expires after a certain period too. Woe to you if you continue to be poor. And then there is the issue of asset tests- meaning they don't just look at your income, they also look at your assets. For people under the age of 65 without special conditons, there is ostensibly no asset test for Medicaid in most states (For people over 65 there generally is an asset test, including in CA- the website doesn't make that clear). But in practice, you have to again qualify for Calworks first, which has a real hornet's nest of an asset test:
http://www.dss.cahwnet.gov/...
You have to have <$2000 liquidity. They even look at what kind of car you're driving. I guess they're still looking for that Cadillac driving welfare queen. Hence asset test is in effect. No sir, they don't make it easy for you.</p>
The Health care reform makes 2 important changes. The first change is the aforementioned uniform eligibility requirement of income <=133% of Federal Poverty Line. <br>P397 of the Senate Bill HR 3590; Section 2001 (a)(1)(C)(VIII)
beginning January 1, 2014, who are under 65 years of age, not pregnant, not entitled to, or enrolled for, benefits under part A of title XVIII, or enrolled for benefits under part B of title XVIII, and are not described in a previous subclause of this clause, and whose income(as determined under subsection (e)(14)) does not exceed 133 percent of the poverty line (as defined in section 2110(c)(5)) applicable to a family of the size involved, subject to subsection (k);
Clear and simple. If your income is less than or equal to 133% of Federal Poverty Level, you qualify for Medicaid. Simple as that. You don't have to borrow somebody's kids or pluck out your eyes to get health care anymore. Imagine that.
Read on to Section 2002 (a)(14)(C)
NO ASSETS TEST.—A State shall not apply any assets or resources test for purposes of determining eligibility for medical assistance under the State plan or under a waiver of the plan.
Don't you love it when a law is short and sweet like that? No asset test for people under 65! You don't have to spend your way to the poorhouse before you qualify for Medicaid.
Further along, we find this change:
P.445 Sec. 2201
‘‘(1) IN GENERAL.—A State shall establish procedures for—
‘‘(A) enabling individuals, through an Internet website that meets the requirements of paragraph (4), to apply for medical assistance under the State plan or under a waiver of the plan, to be enrolled in the State plan or waiver, to renew their enrollment in the plan or waiver, and to consent to enrollment or reenrollment in the State plan through electronic signature;
‘‘(B) enrolling, without any further determination by the State and through such website, individuals who are identified by an Exchange established by the State under section 1311 of the Patient Protection and Affordable Care Act as being eligible for—
‘‘(i) medical assistance under the
State plan or under a waiver of the plan;
or
‘‘(ii) child health assistance under the
State child health plan under title XXI;
‘‘(C) ensuring that individuals who apply for but are determined to be ineligible for medical assistance under the State plan or a waiver or ineligible for child health assistance under the State child health plan under title XXI, are screened for eligibility for enrollment in qualified health plans offered through such an Exchange and, if applicable, premium assistance for the purchase of a qualified health plan under section 36B of the Internal Revenue Code of 1986 (and, if applicable, advance payment of such assistance under section 1412 of the Patient Protection and Affordable Care Act), and, if eligible, enrolled in such a plan without having to submit an additional or separate application, and that such individuals receive information regarding reduced cost-sharing for eligible individuals under section 1402 of the Patient Protection and Affordable Care Act, and any other assistance or subsidies available for coverage obtained through the Exchange;
This is a long section that I had to trim short. (further along there is a very thoughtful section enabling hospitals to enroll patients they determine to be eligible) In effect what this is saying is that the states must offer Medicaid enrollment through the same streamlined Insurance Exchange website where everyone else buying insurance and getting subsidies would go through. At first glance, this might seem like a minor detail not worth delving into. But the significance is this: It de-stigmatizes Medicaid. Right now Medicaid, in most states, is handled through the same offices that handle welfare/TANF. Without dumping on the people who work there too much, let's just say these offices are not exactly the most welcoming places. There is a lot of stigma with just walking through that door. The bureacratic hoops they make you jump through are discouraging at best, and intentionally humiliating at worst. With the new exchange websites, this will no longer be the case. Nobody needs to suffer the stigma of dealing with 'the welfare office'. Nobody needs to feel like a 'charity case' -because everyone buying insurance will go through the same Exchange website. Medicaid will in effect just be part of the continuum of progressive health subsidies which extend all the way up to people earning 4X FPL, well above the national median income.
For most middle class people today, Medicaid is a program for the 'other'. It's heavily stigmatized and ghettoized. With these HCR reforms, Medicaid will lose its stigma and become a broadbased social safety net, like Unemployment, that middle class can embrace as a legitimate entitlement program. Make no mistake about it. This is a seachange summarized in one sentence.