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The Rise And Decline Of The State

Notably, two states have taken recent action to adopt the Medicaid expansion. In November 2022, voters in South Dakota approved Medicaid expansion through a ballot measure and in March 2023, legislation adopting the Medicaid expansion in North Carolina was signed into law, although expansion is contingent on passage of a state budget later in the year. If expansion proceeds as expected in North Carolina, it will become the 41st expansion state (including the District of Columbia), leaving ten states that have not adopted the expansion. This brief presents estimates of the number and characteristics of uninsured people in the ten non-expansion states who could be reached by Medicaid if their states adopted the Medicaid expansion using data from 2021, the most recent year available. It should be noted that this analysis focuses on the number of uninsured people who would be newly eligible if non-expansion states adopted the expansion; the total number of people who would become eligible for Medicaid is larger because it includes people with incomes 100%-138% FPL who are currently enrolled in Marketplace coverage as well as some who may have other coverage. An overview of the methodology underlying the analysis can be found in the Data and Methods, and more detail is available in the Technical Appendices.

The Rise and Decline of the State

The coverage gap exists in states that have not adopted the ACA Medicaid expansion for adults who are not eligible for Medicaid coverage or subsidies in the Marketplace. The ACA expanded Medicaid to nonelderly adults with income up to 138% FPL ($14,580 annually for an individual in 2023) with enhanced federal matching funds (now at 90%). This expanded eligibility for low-income parents and newly established Medicaid coverage for adults without dependent children; however, the expansion is effectively optional for states as a result of a 2012 Supreme Court ruling. As of March 2023, 41 states including DC have expanded Medicaid (Figure 1). As noted above, North Carolina has adopted the Medicaid expansion contingent on passage of a state budget later this spring.

Medicaid eligibility for adults in states that have not expanded their programs is very low. In these states, the median income limit for parents is just 38% FPL, or an annual income of $9,447 for a family of three in 2023, and in nearly all states not expanding (except Wisconsin through a waiver), childless adults remain ineligible regardless of their income (Figure 3). In Texas, the state with the lowest eligibility threshold, parents in a family of three with incomes above $3,977 annually, or just $331 per month, are not eligible for Medicaid. Because there is no pathway for coverage for childless adults, except in Wisconsin, more than three-quarters (76%) of people in the coverage gap fall into this group.

States that have not implemented the expansion have uninsured rates that are nearly double the rate of expansion states (15.4% compared to 8.1%). People without insurance coverage have worse access to care than people who are insured. One in five uninsured adults in 2021 went without needed medical care due to cost and uninsured people are less likely than those with insurance to receive preventive care and services for major health conditions and chronic diseases.

Adults left in the coverage gap are concentrated in three states in the South. Four in ten people in the coverage gap reside in Texas, which has very limited Medicaid eligibility, and consequently, a large uninsured population (Figure 4). One in five people in the coverage gap live in Florida, and 13% in Georgia. In total, 97% of those in the coverage gap live in the South. Seven of the 16 states in the South have not adopted the Medicaid expansion, and the region has more poor, uninsured adults and higher uninsured rates compared to other regions.

People in the coverage gap are disproportionately people of color. Nationally, over six in ten (61%) people in the coverage gap are people of color, a share that is higher than for non-elderly adults generally in non-expansion states (47%) and for non-elderly adults nationwide (40%) (Figure 5). These differences in part explain persisting disparities in health insurance coverage by race/ethnicity.

Despite having low income, nearly six in ten people in the coverage gap are in a family with a worker, and nearly half are working themselves (Figure 6). Adults who work may still have incomes below poverty because they work low-wage jobs. People with incomes below poverty often do not have access to employer based health insurance or if available, it is often unaffordable. The most common jobs among adults in the coverage gap are cashier, cook, waiter/waitress, construction laborer, maid/housecleaner, retail salesperson, and janitor. For parents in non-expansion states, even part-time work may make them ineligible for Medicaid.

If all states adopted the Medicaid expansion, approximately 3.5 million uninsured adults would become newly eligible for Medicaid. This number includes the 1.9 million adults in the coverage gap and an additional 1.6 million uninsured adults with incomes between 100% and 138% FPL, most of whom are currently eligible for Marketplace coverage but not enrolled (Figure 7 and Table 1). Most of the adults who are currently eligible for coverage in the Marketplace qualify for plans with zero premiums; however, even with no premiums, Medicaid could provide more comprehensive benefits and lower cost-sharing compared to Marketplace coverage. The potential number of people who could be reached by Medicaid expansion varies by state.

Almost ten years after implementation of the Medicaid expansion in January 2014, a substantial body of research points to largely positive effects. KFF reports published in 2020 and 2021 reviewed more than 600 studies and concluded that expansion is linked to gains in coverage, improvement in access and health, and economic benefits for states and providers. More recent studies generally find positive effects related to more specific outcomes such as improved access to care, treatment and outcomes for cancer, chronic conditions, sexual and reproductive health and behavioral health. Studies also point to evidence of reduced racial disparities in coverage and access, reduced mortality and improvements in economic impacts for providers (particularly rural hospitals) and economic stability for individuals.

Seven of the last eight states to adopt expansion did so through a ballot measure; however, that is not an option in most other non-expansion states. Every state, except North Carolina, that has adopted expansion since 2019 has done so not through legislative or executive processes, but as a result of a successful ballot initiative. Most recently, in South Dakota voters approved a ballot question in November 2022. Although expansion ballot initiatives have been successful in all seven states where they have gone to voters (Idaho, Maine, Missouri, Nebraska, Oklahoma, and Utah), most of the remaining non-expansion states do not have ballot initiative processes. North Carolina is the first state to adopt expansion through a legislative process since Virginia adopted in 2019.

Expansion could help stem increases in the number of people who are uninsured as the Medicaid continuous enrollment provision ends and states resume disenrollments after a three year pause during the pandemic. All states have experienced significant Medicaid enrollment growth as a result of legislation enacted early in the pandemic that prohibited states from disenrolling people from Medicaid in exchange for enhanced federal matching funds. The increase in Medicaid coverage has been a key factor contributing to the decline in the uninsured rate. When the continuous enrollment provision expires on March 31, 2023 and states resume regular Medicaid disenrollments, millions are expected to lose Medicaid if they are no longer eligible or if they face barriers completing their renewals. While most people who are determined to no longer be eligible in expansion states will qualify for other coverage, either through the Marketplace or through an employer, in non-expansion states, poor parents who are no longer eligible for Medicaid will likely fall into the coverage gap and become uninsured.

Paul Kennedy of Yale University has broken ranks with his colleagues. In a work of almost Toynbeean sweep he describes a pattern of past development that is not only directly relevant to our times but is clearly intended to be read by policy makers, particularly American policy makers. ''The Rise and Fall of the Great Powers'' is, as Mr. Kennedy states, a book that can be read on at least two levels. On the one hand it presents a clearly defined and closely reasoned thesis explaining the subject matter of the title - why nations rise and fall, and why the process is still continuing. On the other, in order to provide the data for his thesis, Mr. Kennedy gives a clearly written and fairly uncontentious history of the rise and fall of Europe and its empires and the confrontation between the superpowers which had followed. He unashamedly endorses the view of the German historian Leopold von Ranke that history is fundamentally about high politics, and that politicians will be better at their jobs if they understand the historical processes of which they form part.

He expands his thesis in the introduction and epilogue. It can be easily summarized: The more states increase their power, the larger the proportion of their resources they devote to maintaining it. If too large a proportion of national resources is diverted to military purposes, this in the long run leads to a weakening of power. The capacity to sustain a conflict with a comparable state or coalition of states ultimately depends on economic strength; but states apparently at the zenith of their political power are usually already in a condition of comparative economic decline, and the United States is no exception to this rule. Power can be maintained only by a prudent balance between the creation of wealth and military expenditure, and great powers in decline almost always hasten their demise by shifting expenditure from the former to the latter. Spain, the Netherlands, France and Britain did exactly that. Now it is the turn of the Soviet Union and the United States. 041b061a72

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