Now that the House-passed American Health Care Act—and the estimated $880 billion in cuts of Medicaid that go with it—has moved to the Senate, much of the debate will focus on the issue of Medicaid expansion. A wildly popular provision of the Affordable Care Act (ACA) that is supported by more than 8 in 10 Americans, Medicaid expansion has provided health coverage to over 14 million people in 31 states and the District of Columbia. Medicaid expansion will be a hotly contested issue among Senate Republicans in the coming weeks as conservative Senators aiming to roll back Medicaid expansion come up against more moderate Republicans who live in states that have benefitted mightily from it. However, as these highly important battles for the future of Medicaid expansion are taking place in Washington, DC, a number of states with Republican-controlled legislatures and/or Republican governors have already taken great strides to slash Medicaid expansion on their own.
Leading the pack among these states looking to pare down their Medicaid expansion programs is Kentucky. This is an ironic development after the Obama administration and Congressional Democrats held up the Bluegrass State as the poster child for the efficacy of the Affordable Care Act in general and Medicaid expansion in particular. Under Democratic Governor Steve Beshear, Kentucky’s Medicaid expansion program provided health insurance for 443,300 low-income Kentuckians and played a huge part in reducing the state’s uninsured rate from 20.4% in 2013 to 7.8% in 2016, the largest such reduction in the nation. Despite the tremendous results, Republican Matt Bevin was elected as governor in 2015 in large part on a promise to repeal and replace the ACA. After working with Republicans in Kentucky’s legislature for 18 months, Bevin is poised to undo much of those gains.
Under the auspices of cost-saving and personal responsibility, Bevin and the Kentucky GOP have crafted legislation that aims to cut the number of residents on Medicaid by 86,000 within five years, which could prove to be an unexpected and devastating blow to low-income residents of a state with one of the worst health outcomes in the country. Among the changes included in this revised Medicaid system are new monthly premiums, co-pays for services, six-month discontinuation of coverage for those who cannot pay their premiums and co-pays, the elimination of automatic vision and dental benefits in favor of a “MyRewards” program where residents earn them by completing incentivized tasks, and mandatory work requirements to maintain coverage. Under the Obama administration, these plans had little or no chances of getting approval from the federal government for their implementation. But, under the Trump administration and with Tom Price leading the Department of Health and Human Services, the likelihood of Kentucky’s plans being approved is very high.
After Kentucky, the state with the largest decrease in their uninsured rate was Arkansas, which is joining Kentucky in the race to significantly cut Medicaid expansion rolls. Last week, the Arkansas state legislature approved a Medicaid reduction package championed by Republican Governor Asa Hutchinson that is arguably more severe than Kentucky’s plan. In addition to implementing work requirements, Arkansas’s Medicaid changes include reducing the maximum income for eligibility to receive benefits from 138% of the federal poverty level, which is the current standard under the Affordable Care Act, to 100% of the federal poverty level, a change that would take coverage away from an estimated 60,000 people.
In addition to Kentucky and Arkansas, Maine recently released a waiver saying that they will ask the Centers for Medicare and Medicaid Services to institute their own reductions to the state’s Medicaid program. Arizona has publicly announced their intent to submit a waiver as well, and Republicans in the Ohio legislature are locked in a battle over whether to put a freeze on the state’s Medicaid expansion enrollment.
The gains that have been made in reducing the uninsured in America since the implementation of the ACA have never been more tenuous than they are right now. It is not enough to advocate protecting Medicaid expansion at the federal level anymore. If HIV advocates want to maintain the Medicaid coverage that is utilized by more than 40% of people living with HIV who are in care, activism and vigilance is required in our statehouses as well.