Tagged Medicaid

New Budget Boosts Health Coverage For Low-Income Californians

Ann Manganello survives entirely off her Social Security stipend: $1,391 a month.

That doesn’t amount to much in the pricey desert enclave of Palm Springs, Calif. — especially for someone who contends with a host of expensive medical problems, including a blood vessel disorder, complications from a recent stroke and frequent bouts of colitis.

“Right now, I don’t really have the money to do much. I just stay here and that’s it,” Manganello said with a sigh, sad at the thought of being stuck in her apartment.

Because she is 71 and has a low income, Manganello qualifies for Medi-Cal, the state’s Medicaid program for disadvantaged people, as well as Medicare, the public insurance program for people 65 and older.

But there’s a catch: Her monthly Social Security check puts her slightly above the income level for free care under Medi-Cal. So, she reduces the amount of income counted for Medi-Cal eligibility by buying a dental insurance policy she doesn’t really need, just so she can qualify for the free coverage and avoid a $672 monthly deductible.

Things are expected to change next year for Manganello and others in similar situations. In the state budget for 2019-20, legislators approved $62.4 million to help about 25,000 older people and those with disabilities get free Medi-Cal. Gov. Gavin Newsom must sign the budget by June 30.

That’s one of several major investments the $215 billion budget makes in Medi-Cal enrollment and services. About 13 million Californians — or about a third of the state’s population — have Medi-Cal.

The spending plan also includes money to restore medical benefits that were cut 10 years ago during the recession, such as podiatry and speech therapy. It also provides full Medi-Cal coverage to low-income young adults ages 19 through 25 who are in the country illegally. That will make California the first state in the nation to offer full Medicaid benefits to unauthorized immigrant adults.

Plus there’s $30 million for outreach and enrollment and $769.5 million to boost the amount Medi-Cal pays participating doctors and dentists.

For Manganello, who worked as a manager for a signage shop in Buffalo, N.Y., before moving west, qualifying for free Medi-Cal would make a tangible difference in her life.

“I could cancel that extra insurance and buy myself a medical alert bracelet. I would also have some money to maybe pay off some other medical bills,” she said. “It would help with groceries, things like Depends. And maybe I could go out to lunch once in a while.”

The Medi-Cal expansions in the budget represent another radical departure by California from the federal government on health care and immigration. In addition to cracking down on illegal immigration, the Trump administration is pushing policies, such as work requirements for Medicaid enrollees, that often lead to reductions in enrollment.

The budget measures also bring California a step closer to Newsom’s goal of achieving universal health care coverage. The state’s estimated 1.8 million unauthorized immigrants, for example, make up roughly 60% of the state’s remaining uninsured residents.

“It seems like what has occurred in California this year is a very conscious, systematic and well-designed effort to close gaps” in coverage, said Judy Solomon, a senior fellow at the Center on Budget and Policy Priorities.

Many other states face similar coverage gaps but few can afford to address them, Solomon said.

‘Senior Penalty’

Most adults who don’t have a disability and are under 65 are eligible for free Medi-Cal with incomes up to 138% of the federal poverty level, or about $17,200 for an individual.

But adults in Medi-Cal’s Aged and Disabled Program have to meet stricter income requirements — up to 122% of the poverty level, or just under $15,240 a year for an individual.

If, like Manganello, they make slightly more than that, they must pay a certain amount of their health costs — essentially, a deductible — before Medi-Cal coverage kicks in. That can translate into hundreds of dollars or more per month.

Linda Nguy, a policy advocate at the Western Center on Law & Poverty, said that many people are simply skipping medical care because they can’t afford the deductible.

“We call this the senior penalty, because basically you’re being penalized with a stricter eligibility limit based fully on your age or disability,” said Amber Christ, an attorney with Justice in Aging, a nonprofit advocacy group focused on senior poverty.

Many states that expanded their Medicaid programs under the Affordable Care Act also have this disparity, Christ said. The 2019-20 California budget would end it by raising the income eligibility threshold for that group to 138% of the poverty level.

Restoring Benefits

During the Great Recession, California, like many other states, cut several Medicaid benefits that aren’t required by the federal government.

Starting Jan. 1, Medi-Cal will restore five areas of coverage: audiology, optical services, podiatry, incontinence supplies and speech therapy.

“People of all ages wear glasses, so this can really benefit anyone,” Nguy said. “But things like podiatry, audiology, speech therapy are probably of most benefit to people with chronic conditions.”

The new budget includes $17.4 million for these services, which could disappear again in 2022 unless lawmakers decide to extend them.

Optional benefits are usually the first to go in bad economic times, and bringing them back can take years. Full dental benefits, also cut during the recession, were restored for adults in Medi-Cal last year.

Immigrant Coverage

Lawmakers allocated $98 million to offer free health coverage for unauthorized young immigrant adults who meet the income requirements, starting next year. Of this, $74.3 million will come from the state, while the rest will come from funds the federal government provides for labor and delivery and emergency care only.

About 90,000 young adults are expected to become eligible in the first year.

Covering young adults became the most controversial health care issue in this year’s budget. Republicans criticized the effort, arguing that Medi-Cal should be fixed before it is expanded.

“Every day, my district offices get calls from my constituents who are unable to see a doctor, even though they are technically covered by Medi-Cal, because so few doctors in my district are able to take the low reimbursement rates that Medi-Cal provides,” state Assemblyman Jay Obernolte (R-Big Bear Lake) said before the Assembly’s budget vote on June 13.

In 2016, California started offering full Medi-Cal benefits to unauthorized immigrant children. The state’s current-year budget allocates $365.2 million to fund that coverage. In February 2019, 127,845 kids were enrolled in the program.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Study: Arkansas Medicaid Work Requirements Hit Those Already Employed

The Medicaid work requirement plan devised by Arkansas and approved by the Trump administration backfired because it caused thousands of poor adults to lose coverage without any evidence the target population gained jobs, a new study finds.

In fact, the requirement had only a limited chance for success as nearly 97% of Arkansas residents ages 30-49 who were eligible for Medicaid — those subject to the mandate — were already employed or should have been exempt from the new law, according to the study published Wednesday in the New England Journal of Medicine.

Yet the state’s mandate — the first of its kind in the nation — resulted in 18,000 of the 100,000 targeted people falling off the Medicaid rolls. And despite administration officials’ statements that many of them may have found jobs, the study by researchers at Harvard found no evidence they secured either jobs or other insurance coverage. In fact, it noted a dip in the employment rate among those eligible for Medicaid.

The researchers said the uninsured rate increased among 30- to 49-year-old Arkansans eligible for Medicaid from 10.5% in 2016 to 14.5% in 2018, while the employment rate fell from about 42% to just below 39%.

While the thousands of Arkansas residents losing Medicaid coverage has been documented since last year, the Harvard study is the first to provide evidence that the change left them uninsured and did not promote employment.

The results, based on a telephone survey of about 3,000 low-income adults in Arkansas, concluded that the law befuddled enrollees and that its mandatory reporting requirements led many to unnecessarily lose coverage.

“Lack of awareness and confusion about the reporting requirements were common, which may explain why thousands of individuals lost coverage,” the researchers wrote.

Asked whether the findings mean the administration should pull the plug on work requirements, co-author Benjamin Sommers, a professor of health policy and economics at Harvard, replied, “It’s time for them to pump the brakes at the very least.”

As millions of nondisabled adults gained Medicaid coverage following the 2010 passage of the Affordable Care Act, conservatives pushed for requiring people to work or do other kinds of “community engagement” to keep their Medicaid, much as food stamps and welfare cash benefit programs do. The Trump administration embraced that ideal and has made Medicaid work requirements a central feature of its plan to restructure the federal-state entitlement program, which has more than 70 million enrollees.

Arkansas put the plan into action in spring 2018.

But in March, a federal judge struck down Arkansas’ mandate and a plan to begin one in Kentucky. U.S. District Judge James Boasberg ruled the work requirement violated federal law because it failed to meet the core objective of Medicaid — getting medical coverage to the poor.

The Trump administration is appealing that ruling and, meanwhile, has approved similar plans in eight other states, including New Hampshire, which is scheduled to start cutting coverage in August for those not meeting the rules. New Hampshire’s law also is being challenged in court by Medicaid advocates.

Six more states have pending applications to add work mandates.

Seema Verma, administrator of the Centers for Medicare & Medicaid Services, defends the work requirements, saying they “are not some subversive attempt to just kick people off of Medicaid. Instead, their aim is to put beneficiaries in control with the right incentives to live healthier, independent lives.”

Arkansas officials disputed the thrust of the study, noting that the requirement was short-lived because the judge intervened before it was in effect even a year and researchers did not find out why people who were dismissed from Medicaid didn’t reapply.

“So you cannot describe this as the robust evaluation that we want and expect of a demonstration project that truly has national significance,” said Amy Webb, a spokeswoman for the state’s Medicaid program. “The best way to get answers to everyone’s questions about the impact of work and community engagement requirements would be to let Arkansas continue what was started and conduct a true evaluation that follows people over time.”

Under the Arkansas law, targeted enrollees were notified by the state via mail and informational flyers that they were required to work 80 hours a month, participate in another qualifying activity such as job training or community service, or meet criteria for an exemption such as pregnancy, a disability or parenting a child.

If they were out of compliance for three months during a calendar year or failed to report their status to the state through online reports, they could lose coverage.

For the first several months of its new mandate, Arkansas required enrollees to use an online portal for that reporting, a problem since 20% lacked internet access and another 20% lacked fast broadband. The state online portal also was unavailable after 9 p.m. each day.

The study found one-third of individuals subject to the policy had not heard anything about it, and 44% were unsure whether the requirements applied to them.

The findings back up arguments from advocates for the poor and nonpartisan experts that many Medicaid enrollees already have jobs. They also directly contradict claims by federal and Arkansas officials that many of those who lost coverage found a job.

In a hearing before the Senate Finance Committee earlier this year, Health and Human Services Secretary Alex Azar noted that only 1,452 of the 18,000 people who lost coverage because of the work requirement rules reapplied for Medicaid. He added that likely meant most no longer needed the government assistance.

“That seems a fairly strong indication that those people got a job and insurance elsewhere and didn’t need the coverage,” Azar said.

Sommers said the Arkansas experiment answers many questions about how work requirements could function nationally, although he acknowledged that other states might do a better job promoting the program and making it easier for enrollees to report their status.

“There are just not that many people [enrolled in Medicaid] who aren’t working but could,” Sommers said.

He noted Arkansas added the work requirement feature without adding new funding for job training or child support to help people who want to work.

Federal officials who approve the waivers allowing states to use work requirements should take note of the results, he said. “It does not make sense to keep approving the same waiver without doing anything differently,” Sommers said.