Question

"The Supreme Court's 2012 ruling that states could decide whether to participate in the health law's Medicaid expansion program was controversial." Write a response to the statement given describing the Medicaid expansion program and why some states did NOT participate. Include how the decision to participate in the expansion program affects access, quality, and healthcare costs for providers. Don't forget to describe the pros and cons.

Answer 1

o The aim of the Affordable Care Act was to resolve systemic health inequalities for millions of Americans without health insurance. Medicaid reform was a central component of the programme, since it was intended to expand coverage for low-income people, a demographic at heightened risk for inequalities in access to the health care system and health outcomes

o Several studies suggest that Medicaid expansion will reduce insurance-related inequalities and generate hope surrounding the potential effect of the Affordable Care Act on poor people's health. However, many impediments to Medicaid 's expansion and inadequacies within the Medicaid programme itself will reduce its original effect. Specifically, the Supreme Court's decision to revoke the provision of the Affordable Care Act requiring all states to implement the Medicaid extension allowed half of the states to forego coverage extension, leaving millions of low-income citizens without insurance. Furthermore, Medicaid is an incomplete network with lower payment rates, less covered programmes, compared to many private plans, and insufficient recognition by those receiving preventive and advanced treatment. These restrictions would reduce the possible effect of expansion on patients with respiratory and sleeping or vital disease conditions. Despite its imperfections, the more than 10 million low-income people who receive insurance as a consequence of the extension of Medicaid are likely to have improved access to healthcare, decreased Out-of-pocket spending on health insurance, and eventually increasing public wellbeing.

o There is a large risk of states that refuse to expand access to Medicaid that millions of under-income parents and childless adults will remain without health insurance. Paradoxically, many states that opt not to extend Medicaid coverage have the most potential to benefit because they have a significantly higher proportion of people without health insurance. Many uninsured people in these states are low-income, have no access to employee-based benefits, and after reform will remain ineligible for the existing Medicaid coverage in their state. In addition, their wages will be too low ( i.e., less than 100% of the federal poverty level) to qualify for premium health insurance subsidies, which would otherwise cover the purchase insurance expenses through state insurance exchanges. These people are left in a "coverage gap" where both premiums are ineligible to encourage the purchase of private insurance because their income is too low and Medicaid ineligible because their income is too high.

o Failure to expand Medicaid access in these states can also have significant consequences for covered patients receiving care through the safety net. Those who fall into the coverage gap are likely to continue to face barriers to non-emergency treatment while seeking care with related poorer health outcomes and potentially serious financial difficulties.

o Failure to expand Medicaid is likely to have adverse health consequences for indigent women: more than half of states that decide not to expand Medicaid have higher than average rates for women without health insurance. Safety net health care facilities and hospitals in these states — programmes that usually serve marginalised and disadvantaged communities — are more likely to suffer from budget shortages and diminished compensation from Disproportionate Share Hospital while they continue to bear the brunt of uncompensated care costs.

o By offering an effective solution for health inequality, Medicaid expansion under the Affordable Care Act is expected to be a major move forward in resolving safety net coverage gaps. Evidence from previous expansion of insurance indicates that the extension of Medicaid under the Affordable Care Act would boost self-reported health, increase the use of preventive and primary care services and decrease financial strain due to medical illness.

o Early estimates indicate that by February 2014, 3 million new Medicaid applications of the 6.3 million federally qualified individuals have been registered from states that have implemented Medicaid expansion; five times more than those that do not extend Medicaid. Although Medicaid expansion is a promising first step towards improving insurance-related disparities in health care, studies in our specialty have shown consistent differences in health outcomes for Medicaid patients compared to private insurance.

o Furthermore, without widespread implementation of Medicaid expansion, and wide variation in income eligibility thresholds among states that choose to expand, there will be significant coverage gaps for millions of Americans, potentially exacerbating disparities in health care in those regions. Residents in states that approve the Medicaid extension will also face difficulties in obtaining required care due to substantial gaps in critical health benefits, financial pressure arising from cost-sharing requirements aimed at Medicaid recipients, and limited access to specialists relative to private insurance insured.

o In addition to focusing on patients, Medicaid expansion will increase clinicians and health systems capacity to identify and resolve health inequalities. Access to health care plays a minor role amongst all recognised health contributors. Before the United States fully tackles inequities in certain social and economic fields that are vital to wellbeing, such as attitudes, education, income, and environment, inequalities in health will persist.

· In addition, promoting strengthening existing policies to improve patient access to pulmonary, vital, and sleep medicine services while reducing barriers to providers will achieve the goal of increasing access to timely outpatient and acute care services for all of our patients and enhancing health outcomes at both individual and societal levels.

· Even if Medicaid expansion were completely enforced in all states, the existing policy would still marginalise significant portions of the population. Undocumented immigrants, and immigrants who have been in the United States for less than 5 years, are legally present, are unable to apply for Medicaid.

· The federal government has urged states to also recognise same-sex marriage for Medicaid eligibility determination; however, this decision ultimately rests with each state. These major gaps in health care coverage and delivery pose complex policy problems that require a more thorough legislative response.