What Health Care Reform Means for: Medicaid Recipients

by Sabrina Shankman and Olga Pierce, ProPublica

ProPublica used results from a questionnaire it did with American Public Media’s Public Insight Network to look at how the proposed health care reforms will actually affect people facing common health-care coverage situations.

Sarah Goodwin, 25

Location: Harveys Lake, Pa.

Health Care Status: Medicaid recipient

Household Income: $0, but she has a Social Security application pending

When Sarah Goodwin, 25, was diagnosed with Chronic Fatigue Syndrome, she was a senior in college in Maine. This photo is from just before she became sick. After running out of savings to cover her health costs, and unable to work because of her condition, Goodwin went on Medicaid. Only 15 states currently enroll low-income adults in Medicaid if they do not have children, but both health care reform bills would extend coverage to that group.

Her story:

Sarah Goodwin, who has chronic fatigue syndrome and a slew of immune deficiencies, relies on Medicaid for health coverage.

Medicaid serves low-income and disabled individuals, with the federal government paying for about 60 percent of the program (with a temporary boost of that percentage included in the stimulus bill) and states paying for the rest. Goodwin has experienced firsthand the wide leeway that states are given in determining who is eligible and what services are covered.

In Maine, Goodwin was able to get only temporary Medicaid, which meant she was constantly reapplying, and having to fight to get the medications she needed. Two years later, she has moved from Maine to Pennsylvania, where she says she’s had a better experience. “The Medicaid people here are really helpful,” she says.

Most of the Medicaid-covered services that Goodwin uses are free, with some doctors charging a $3 co-pay.

“I’m really happy with the Medicaid that I have right now, and I would hope that it would stay the same,” she says.

For those, like Goodwin, who have chronic conditions, Medicaid can be a lifeline.

“If I ever miraculously get better, I’m still going to be uninsurable,” she says.

What changes would mean for her:

Goodwin has seen the two sides of Medicaid: first in Maine, where the program didn’t meet her needs, then in Pennsylvania, where it did. Some states offer coverage for children from families with incomes as high as three times the federal poverty line. Other states cut off eligibility at 100 percent of the poverty line. Some states cover childless adults, some don’t. Physical therapy may be covered with a $1 co-payment – or not at all.

This variability among states is one of the major complaints about Medicaid, and is one that the Senate and House health care bills attempt to remedy. (You can check out the highs and lows of coverage here.)

Both the Senate and House bills would require all states to have the same income cutoff for Medicaid.

The Senate bill would expand Medicaid to cover those with incomes up to 133 percent of the federal poverty line (about $14,000 for a single person) starting in 2014, while the House bill would expand it to 150 percent, or about $16,000, a year earlier. The Congressional Budget Office estimates that both bills would result in as many as 15 million new Medicaid enrollees by 2019.

Both bills would make low-income adults, like Goodwin, eligible for Medicaid coverage, even if they don’t have children. Currently, only 15 states offer such coverage — which the states pay for on their own. And many of those states have closed their programs to new enrollees because of funding concerns.

To address disparities among states in benefits for childless adults, both bills would define a minimum benefits package, which would include mental health services. The House bill goes one step further, requiring that beneficiaries be offered preventive services and vaccines with no co-payment.

The biggest difference between the House and Senate bills regards another disparity among states that can have a big effect on how easy it is to get care. Medicaid as a whole tends to pay less than other insurers for health services – and in some states a lot less. This means it may be difficult to find doctors willing to accept Medicaid patients.

To avoid this, the House bill would incrementally increase Medicaid payments for primary care to the higher rates paid by the Medicare program. The Senate bill has no such increase.

Medicaid is already notoriously expensive, accounting for about one-fifth of all state spending. Critics of the expansion have argued that expanding the program is an unfunded mandate that would break states’ already strained budgets.

Under both bills, the federal government would pay a higher share of the cost of new Medicaid enrollees than it pays for people in the program now.

In the House bill, the federal government would pay the full cost of coverage for new enrollees until 2015, when the percentage that Washington covers would be set at about 90 percent.

The Senate bill would pay the full cost of new enrollees for the years 2014 to 2016, then gradually adjust the share that Washington pays. From 2019 onward, the federal government would pay 32.3 percentage points more of the cost of each new enrollee. (This would be about 90 percent on average, but with considerable variation from state to state.)

There’s a catch though: States that already offer coverage to adults beyond federal requirements would get less federal help in the years before 2019. Not surprisingly, these states aren’t happy about this, arguing that they are being penalized for their efforts to cover more uninsured residents.

Though the changes would not be cheap for states or the federal government, for Goodwin, they would likely mean easier access to a bolstered Medicaid program.

Write to Olga Pierce at Olga.Pierce@propublica.org.

Want to know more?

To learn more about ProPublica and see other stories its investigative reporters have covered on health and other topics, please go to: www.propublica.org. Follow ProPublica on FacebookandTwitter, and get ProPublica headlines delivered by e-mail every day.