Marketplace Launch Will Highlight Need for Medicaid Expansion

Tomorrow marks the start of the first open enrollment period for the health insurance marketplace that was created as part of the Affordable Care Act (aka the ACA, Obamacare, health reform). While the enrollment scene looks different in every state, one common thread in both Kansas and Missouri is that neither state has opted to expand Medicaid, as allowed for by federal law.

By way of a quick explanation, the marketplace (see and Bridget’s Blog for more info) will provide a one-stop shop for consumers to compare private health insurance options, access Medicaid and other public insurance options, and receive subsidies to make their insurance more affordable.

Subsidized coverage will be available for those between 100 percent and 400 percent of the federal poverty level (FPL), and Medicaid will be available for parents below approximately 30 percent FPL (the exact number depends on which side of state line you are on).

So this is how coverage looks for incomes up to 400 percent FPL:

The glaring omission? The huge swath of the uninsured who make too much for Medicaid and not enough for subsidies on the marketplace.

The Affordable Care Act originally required states to expand their Medicaid eligibility levels to 135 percent of the federal poverty level and begin providing benefits to childless adults, which isn’t currently the case. The U.S. Supreme Court determined that mandating this expansion was unconstitutional. Instead, states had to opt to expand Medicaid, with the federal government bearing 100 percent of the costs up front and eventually leveling off to 90 percent.

State legislators and governors in both Kansas and Missouri have not elected to expand Medicaid — yet. I anticipate that the marketplace open enrollment period will fundamentally change the conversation around Medicaid expansion in both states in the following ways:

  • Until now, there has not been a mass outcry in support of Medicaid expansion. Despite the great work of many advocates throughout Kansas and Missouri (many of whom are Health Forward grantees – kudos to you all!), the issue of Medicaid expansion has never been salient enough to mobilize the uninsured. As folks in this coverage gap attempt to access the marketplace and realize that they have fallen between the cracks, I expect the public outcry to rise ever louder.
  • Regardless of party affiliation, there is something patently backward about the fact that we have a coverage gap in the lowest ends of the socioeconomic spectrum. The current coverage system creates bad incentives, potentially even encouraging those making 50 percent FPL to decrease their income in order to qualify for the Medicaid system as it looks now.
  • The marketplace launch means that health reform is here to stay. Sure, there have been more than 40 unsuccessful federal attempts to repeal the ACA. With the launch of the marketplace, I anticipate that there will be some recognition (even if it’s a begrudging one) that we are looking at a reformed health delivery system. I think that this recognition will prompt a renewed effort federally and in states to stop talking about repeal and start thinking about the reforms and tweaks needed to make the ACA as good as it can be.

So, stay tuned! The previous legislative sessions in both Kansas and Missouri were chock-full of great efforts to expand Medicaid, but ultimately neither legislature opted in. The dynamics of expansion will fundamentally change as the marketplace launch surfaces the vast crowd of uninsured who fall through the cracks of health reform.

Safety Net

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