The October (Medicaid) Surprise, Commentary by Aaron Katz

Aaron Katz Photo credit: I-TECH

Aaron Katz
Photo credit: I-TECH

All eyes were focused on the rollout of “Obamacare” on October 1, 2013.  Of course, October 1 wasn’t the start-up of the Affordable Care Act – that was three years earlier, when various new insurance regulations and small business tax credits kicked in. Rather, it was the beginning of the ACA’s coverage expansions.

Still, the coverage expansions are critical parts of the law, so the focus wasn’t unwarranted, just a bit hyperbolic.  What was interesting was how much attention the news outlets, bloggers, and pundits placed on the new federal and state health insurance “exchanges” and how little on the expansion of Medicaid.

We suffered daily, nay, hourly reports raising apocalyptic questions: Would the web portals work?  Would people be able to navigate them?  Would the state and federal information systems be able to talk to each other?  Would young people sign up?  For some, the answer seemed, a priori, “no!” and that meant Obamacare was a failure, in its entirety.

But the pundits paid little attention to Medicaid, even though it was perhaps the most evidence-based part of the ACA.  Indeed, “Obamacare enrollment” often just ignores Medicaid expansion, as a January 24 National Journal headline did (“Obamacare Enrollment Hits 3 Million,” except that was only sign-ups for private insurance).

We have long experience – nearly 60 years – with Medicaid, and we know with some certainty that if we expand eligibility and lower administrative hurdles, more people will enroll and fewer people will be uninsured.

So, it seems to have come as some surprise – a surprise no doubt abetted by the Supreme Court’s decision to make Medicaid expansion an option for states and by on-going political attacks against ACA and Medicaid – that the number of people obtaining Medicaid coverage through the insurance exchange far exceeds those getting private insurance coverage. By early February, newly eligible Medicaid enrollment in Washington hit nearly 185,000, 36% higher than the target for April.  Compare that to the 91,000 who have paid for private coverage though the Health Benefit Exchange, 30% below the state’s January 1 target.

Don’t get me wrong, this state’s insurance exchange has performed admirably compared to most other states’ exchanges and the federal exchange.  The stark difference between Medicaid and private insurance sign-ups is, though, a testament to the benefits of making use of a tried and true program, one that we know works in the real world.

Makes one wonder, if Congress had used strongly evidenced-based strategies, what might the ACA have looked like today?

Aaron Katz is a Principal Lecturer in the University of Washington’s Department of Global Health and a contributor to State of Reform.