By 2017, Medicaid expansion had provided health coverage to more than 17 million low-income adults in 32 states and helped lower the overall uninsured rate in the United States to 8.8 percent. But critics have long looked for highly misleading ways to undermine the program, such as portraying improper payments and enrollment errors as Medicaid beneficiary fraud or claiming Medicaid expansion has fueled the opioid crisis. The latest is an attempt to argue that the people enrolling in Medicaid do not qualify.
In a recent Wall Street Journal (WSJ) commentary entitled “Obamacare’s Medicaid Deception,” authors Brian Blase and Arron Yelowitz draw inaccurate conclusions about the Affordable Care Act’s (ACA) expansion of Medicaid to low-income adults. The authors wrongly assert that “most people who gained coverage have enrolled in Medicaid regardless of income.” The commentary is based on a National Bureau of Economic Research (NBER) working paper using income data and coverage source reported by individuals in the Census Bureau’s Annual Community Survey (ACS). But the NBER study, co-authored by Yelowitz, does not make adjustments to the ACS data to simulate the complex construct of how income and household size are actually counted and verified for adults in Medicaid. Nor is it based on actual administrative enrollment data. To explain his error, it would be most appropriate to discuss how the ACS calculates income, since the primary but unproven conclusion of the commentary is that a large share of individuals with Medicaid coverage are not income-eligible. In fact, there are many reasons ACS survey income data would not align with the way income is counted in Medicaid. First, Medicaid eligibility is based on taxable – not gross – income. Second, certain types of income, such as Supplemental Security Income for low-income, disabled adults, child support, and Veterans benefits are not included in household income when determining eligibility for Medicaid expansion adults. Third, household size for Medicaid is based on the number of individuals in the tax-filing unit for tax-filers while only parents and children are counted in non-tax filing households. The ACS household requests information for everyone in the household, including non-married partners, in-laws, roommates, and other individuals who should not be counted in determining the household size or income for Medicaid. This brief from the State Health Access Data Assistance Center (SHADAC), although focused on estimating Medicaid eligibility for the adult population pre-ACA, illustrates how results differ when adjusting Census data appropriately for household size and income. The study found that relying on unadjusted data underestimated the number of adults with income at or below 138 percent of the federal poverty level (FPL) by 16 million, or 8.9 percent, in 2010. Importantly, Medicaid eligibility is not determined based on self-reported income. All income must be verified through trusted electronic sources when possible, or through documentation provided by the enrollees. Additionally, Medicaid eligibility is based on current monthly income – not total income in the past 12 months - as income volatility is significant among low-income individuals. According to this Health Affairs study, more than one-third of individuals with income below 200 percent FPL shift in or out of Medicaid eligibility in a six-month period and, within a year, 50 percent will. Individuals who experienced a decrease in income as a result of job change or reduction in hours may qualify for Medicaid mid-year but appear to be over-income for the year overall. Another crucial point to understand is that income thresholds can vary by population within Medicaid. Pregnant women, individuals with disabilities, and those needing long-term services and supports may qualify for Medicaid at higher incomes. For example, according to data from the Kaiser Family Foundation, the median eligibility level for pregnant women is 205 percent of the federal poverty level (FPL) and the median income for disabled individuals to “buy-in” to Medicaid is 256 percent FPL, both well above the Medicaid adult expansion threshold of 138 percent FPL. The NBER study attempts to test its results against these potential alternative pathways, but it does not provide a sufficient explanation to fully understand how it conducted these sensitivity tests. And while the sensitivity analysis appears to substantially change their results, the authors still focus on the unadjusted numbers. As a result, the commentary’s conclusion that “virtually all of the increase in participation for income-ineligible adults is coming from those with no obvious path to qualify for Medicaid” is completely unsubstantiated. The authors try to buttress their unfounded conclusion by grossly misrepresenting the results of a legislative Medicaid audit in Louisiana with their statement that “82 percent of expansion enrollees were ineligible at some point during the year they were enrolled.” The fact is that the Louisiana audit first identified fewer than 20,000 enrollees – less than 4 percent of the estimated 500,000 expansion enrollees – whose income appeared to exceed the Medicaid eligibility level at some point during their enrollment. From that group, the audit pulled a targeted sample of just 100 individuals with the highest wage amounts during a study period over 21 months and determined that 82 people were ineligible for coverage for some period of time (without taking into consideration the relevant rules and actual data sources that were appropriately used to calculate eligibility initially). In no way does the audit conclude that 82 percent of all expansion enrollees were ineligible at some point during their enrollment as authors incorrectly declare. The bottom line is this – the NBER working paper used as the basis for the WSJ commentary is relying on unadjusted self-reported survey data as a proxy for actual Medicaid income eligibility and enrollment. It cannot and should not be construed as an audit of improper enrollment. The ACS is a reliable data source but should not be used to draw misleading conclusions about income eligibility and enrollment in Medicaid as the authors do. Instead, researchers should follow best practices in using public data – such as the State Health Access Data Assistance Center and the Urban Institute do -- to simulate how eligibility is determined in Medicaid. If you want to know more about the business health insurance then please send your queries by dropping a comment below.
2 Comments
3/10/2019 03:05:35 am
The latest is an attempt to argue that the people enrolling in Medicaid do not qualify.
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16/10/2019 11:21:24 pm
Thanks for sharing this article! Keep sharing the useful information.
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