When Obama administration defined the groundwork for the Patient Protection and Affordable Care Act, it defined a clause that would cover the needs of people who most require the benefits and protections of a health insurance plan. This clause was that of Medicaid expansion, which asked states to expand their Medicaid coverage to cover people up to 138 percent of the federal poverty line. However, not all states were in favor of this move, as these states felt that this would put undue stress on the already financially struggling Medicaid program. Almost all these states were GOP led.

After a fight in the Supreme Court that weighed this mandate of the ACA, the expansion was deemed optional, and ACA lost a major edge. In states that chose not to expand the Medicaid program, a gap in coverage was observed for people between 100 – 138 percent of the federal poverty line. Following this, states that did not move for the expansion faced several new challenges. One new challenge is wreaking havoc on the economics of Medicaid – hospitals have more unpaid medical bills in states which chose not to expand Medicaid.

As per a report available from the Department of Health and Human Services, the decline in the number of uninsured will benefit hospitals by as much as $5.7 billion in unpaid hospital bills. However, if you drill down into this number, the states that have expanded Medicaid are experiencing a better outcome. The 25 states that did the expansion will have about $4.2 billion less in unpaid bills, which is about a 25 percent decrease. On the other hand, the states that didn’t expand will have only $1.5 billion less in unpaid bills, which is a 9 percent decrease. As evident from the report, that is a stark absolute and relative decrease.

In simpler words, the report shows that there is a direct, explainable correlation between Medicaid expansion and the quality of health insurance coverage for that state. For instance, the report exhibits that a lesser number of people are going to hospitals without health insurance or any other means to pay for the treatment they seek. The decrease is all round, but it is more prominent and more substantial in states which decided to expand Medicaid.

Another takeaway from this report is that the expansion has had a direct effect on the number of uninsured in the state, especially in the low-income group. The study estimates that about 10.3 million people have newly acquired health insurance under Obamacare, and that 7.9 million more people have newly enrolled in Medicaid or the connected CHIP program after Obamacare rolled out. Another 7.3 million people have acquired health insurance under public exchanges through the law. Contrary to this, the states that decided not to go for Medicaid expansion have about 4.8 million uninsured, who would have otherwise been eligible for coverage under expanded Medicaid.

Amid this, hospitals are trapped in a precarious situation. Even after endorsing the ACA for ensuring that more people get health insurance and fewer patients are unable to pay for hospital care, they are stuck with large bills that they are unable to play. Hospital groups in Texas and Florida even tried to lobby for Medicaid expansion after the Supreme Court ruling came out last year, but to no avail. With such high amount of unpaid bills and available information making Medicaid expansion a viable option, hospitals are keeping their fingers crossed in the hopes of a Medicaid expansion in their state.

In the light of these new numbers and changing sentiments, some states are finally moving toward Medicaid expansion. Pennsylvania and New Hampshire are two of the new entrants in the Medicaid expanded state list, making the count 27 plus District of Columbia. The Obama administration is already trying to make more states sign on for expansion, and it looks like the available studies and collated data point to one single claim – Medicaid expansion can fill in the gaps left in states and help them realize the true worth of Obamacare. Collectively, the administration and available facts might be able to coerce even the most solid Republican states into expanding Medicaid in a short period of time from now.

The uninsured percentage of the US population is at an all-time low of 13.4 percent from the 18 percent before the Affordable Care Act was rolled out. Approximately 15 million people who did not have health coverage before Obamacare enrolled in a health insurance plan under this new law without any discrimination on the basis of pre-existing medical conditions. The ACA also served as a catalyst for 6 million people who were deemed eligible for expanded Medicaid coverage. The newly eligible applied for Medicaid, but were left in a lurch when their applications went into a pending status. Nearly 1.7 million applications are in backlog, and people are waiting to get through the system.

As the second enrollment period nears, the Medicaid department is already stretched thin for resources, and they will soon have work around eligibility determinations, complicated application hurdles and drying up state funds in a smaller time window. However, the administration is trying to best these challenges. Here are some strategies the Medicaid directors are putting together to sail through these troubled waters.

1)  Setting Up Dedicated Centers for Customer Help – The first enrollment period saw customers flocking to navigators and exchange authorities for help. People consulted the official healthcare.gov centers for all questions and troubles they were facing while enrolling. A similar trend manifested for Medicaid, people were quick to call to check on applications and inquire on the status. In the second enrollment, Medicaid coverage will reach out to people who did not get covered in the first period, and that means more questions and more queries that are community specific. Since there will be no additional resources, the call volume per navigator will be high, and the navigators need to be ready. Further, since special communities will be the central theme this year, navigators with any other primary language than English will be preferred. In-depth training for these navigators are already underway and will help educate representatives on the most commonly asked questions and the  typical challenges their callers might face in the second enrollment period.

2)  Dedicated Backlog Management – Other than gearing up for new applications, a dedicated backlog management process is in the works for handling the Medicaid applications currently stuck in the system. Most of these applications are the ones which require eligibility redetermination; and that requires a complete pacing of the app through the system. In order to clear these backlogs, an escalation system is being created that will separate complex applications from the simpler ones and allow those to go through smoothly. This escalation system will weigh the application on the basis of complexity and decide whether to pass it through or take it to the next level.

3)  New Application Handling – With the above escalation system, the administration plans to speed up new application handling. Other than the escalation system, the newer applications will also go through a decentralized enrollment system. The decentralized enrollment system will rely on district and county offices to process eligibility. For counties and districts where the pressure of applications is too much, a central system will be established that will help ease off the load. A review of the implemented improvements will ease out bottlenecks and control the risks of the system.

Due to mounting pressure and only a short time left before the second enrollment, the administration will have to implement these strategies as soon as possible. While contact centers are already making progress on trainings and implementation, backlog clearance and new application handling are far from satisfactory. If the administration is unable to streamline these issues before November 15th, the going will be smooth, else the Medicaid enrollments could turn out to be a bigger challenge than the government had expected.

Medicaid has long been a hot discussion point for Democrats and Republicans, and Medicaid Expansion is a new avenue where the sides are locking horns across all states. The case in point being the support given to Obamacare’s effects through the Medicaid expansion, which will work as a strategy to cover those up to 138 percent of the federal poverty line under the safety net of Medicaid. The expansion would specifically target people that are not being covered under PPACA’s laws and provide quality health and care to the underprivileged. However, the administration has not been able to reach an agreement with all the states on the aspect of Medicaid expansion, and 17 states have chosen not to expand Medicaid for supporting ACA.

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Back in 2010, when Obamacare was unfolding its propositions and plans for the implementation, a crucial aspect of the law was coverage to people below the federal poverty line, up to 138 percent of the federal poverty line through a proposed Medicaid expansion. However, in 2012, the proposal to expand Medicare coverage was shot down by Supreme Court. Twenty-four states are currently refusing  to align with the expansion (six of those are currently having an open debate on this issue but for the purpose of this post, I am counting them as a “not expand”), and have triggered a health law coverage gap for individuals who need subsidized health insurance coverage. The main, collective concern of these states was the financial liability that Medicaid expansion will add to the already struggling economy of the U.S.

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When Obamacare was designed, it had aspirations that all Americans would have health insurance coverage, regardless of age, income level or health. As we know, the act has been hotly contested and challenged all the way to the U.S. Supreme Court. But there have been some casualties. The health-law coverage gap, an unfortunate consequence of amends to PPACA, is one such casualty.

Before we move into how and why, let’s first understand what we mean by the health-law coverage gap. Rewinding back to 2010, Obamacare was designed to provide health insurance to the underprivileged through a two-pronged approach – new federal subsidies and expanded Medicaid program. For people earning up to 138 percent of the federal poverty line, Medicaid was to be expanded for covering their health insurance requirements. For people in 138 – 400 percent of the poverty line, the law proposed federal subsidies that could be attained while enrolling through federally facilitated marketplaces.

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