Affordable Care Act: Medicaid Expansion. Medicaid Expansion I.NFIB v. Sebelius: Constitutionality of Medicaid Expansion under the Affordable Care Act.

Affordable Care Act: Medicaid Expansion

Medicaid Expansion

I. NFIB v. Sebelius: Constitutionality of Medicaid Expansion under the Affordable Care Act

Constitutionality of Expansion

Supreme Court holds in NFIB v. Sebelius:

Medicaid expansion violates Congress’ spending power as unconstitutionally coercive of states because:

1. States not given adequate notice to voluntarily consent to expansion, and2. HSS Secretary could potentially withhold all of a

state’s existing federal Medicaid funds for non-compliance


Medicaid Expansion is a “gun to the head” because the “threatened loss of over 10 percent of a state’s overall budget….is economic dragooning that leaves the states with no real option but to acquiesce.”

- Sebelius, at 54.


Coercive But.........

Supreme Court fashions a “remedy” to overcome the coercion


Supreme Court’s remedy for coercion:

Remedy is to limit HHS Secretary’s power to withhold existing federal Medicaid funds for state non-compliance with Medicaid expansion

Makes Medicaid expansion optional for states

Supreme Court on ACA’s Medicaid Expansion

Issue Vote

Support Oppose

The ACA’s Medicaid Expansion is Unconstitutionally Coercive

7:2 Roberts, Breyer, Kagan, Scalia, Kennedy, Thomas, Alito

Ginsburg, Sotomayor

The Secretary’s enforcement authority should be limited

5:4 Roberts, Breyer, Kagan, Ginsburg, Sotomayor

N/A

The entire ACA should be invalidated

4:5 Scalia, Kennedy, Thomas, Alito

Roberts, Breyer, Kagan, Ginsburg, Sotomayor

Medicaid Expansion

I. NFIB v. Sebelius: Constitutionality of Medicaid Expansion under the Affordable Care Act

II. Past, Present, and Future: A glimpse at Medicaid Establishment and Expansion

Past: Establishment of Medicaid

Past: Medicaid Establishment

Establishment of Medicaid

Established in 1965 as a jointly funded cooperative between federal and state governments

Purpose: Provide medical benefits to those who have either no or inadequate medical insurance

Program requirements: Established by each state and eligibility varies per state


Tennessee’s Response to Medicaid Enactment

Established TennCare in 1994 Serves roughly 18-19% of the

state’s population Two types of TennCare:

TennCare Medicaid and TennCare Standard


For: Tennesseans who are

eligible for Medicaid Groups covered include:

Children under 21, pregnant women, single parents of minor child, elderly, and disabled

Income limits are applicable

For: Children under 19 who

are already enrolled in TennCare Medicaid AND

Lack access to group health insurance OR

Time of eligibility for TennCare Medicaid is ending and they no longer qualify

TennCare Medicaid TennCare Standard

Present: Tennessee without Medicaid Expansion


Current source of Tennesseans HealthCare coverage

Location

Employer

Individual

Medicaid

Medicare

Other Public

Uninsured

Total

TN 47% 5% 18% 14% 2% 14% 100%


Tennessee Compared to United States

Future: Medicaid Expansion

Affordable Care Act gives states the option to expand Medicaid coverage to nonelderly adults with incomes up to 138% of the federal poverty level (FPL)



Means that Tennessee can extend TennCare coverage to individuals up to 138% FPL

Persons in household

Poverty Guideline

133% 138% 400%

1 $11,490 $15,282 $15,856 $45,960

2 $15,510 $20,628 $21,404 $62,040

3 $19,530 $25,975 $26,952 $78,120

4 $23,550 $31,322 $32,500 $94,200


No deadline by which states must decide whether to expand or not

No partial expansion- all or nothing Effects of expansion


Effects of Expansion

Effect on people below 100% FPL






Financial Effects of Expansion

Financial Effects of Expansion

100% for first three years (2014, 2015, 2016)

95% in 2017 94% in 2018 93% in 2019 90% thereafter

Approx. $31 million in 2017

Approx. $95 million in 2019

Federal Government will pay

Tennessee’s Increased Costs




Financial Effects of Expansion Effects of the Eligible but not

Enrolled (EBNE)

Effects of the EBNE

Individuals who are currently eligible for Medicaid but not enrolled will likely go to exchanges and be automatically moved to TennCare

State will pay approximately 35% of the cost of covering this group

“Woodwork effect” May be over 60,000 EBNE individuals

who enroll in TennCare




Financial Effects of Expansion Effects of the Eligible but not

Enrolled (EBNE) Effects on healthcare

availability

Effects on Healthcare Availability More than 220,000 (and possibly up to

370,000) additional Tennesseans who are not currently eligible for TennCare would become eligible if expanded

Expansion would result in 24.7% reduction in overall number of uninsured in Tennessee

Where do States stand on Expansion?


Where do states stand?

Medicaid Expansion?

Affordable Care Act: Medicaid Expansion. Medicaid Expansion I.NFIB v. Sebelius: Constitutionality of Medicaid Expansion under the Affordable Care Act.

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