Affordable Care Act: Medicaid Expansion

1. Affordable Care Act: Medicaid Expansion

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

3. 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, and 2. HSS Secretary could potentially withhold all of a state’s existing federal Medicaid funds for non-compliance

4. Constitutionality of Expansion 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.

5. Constitutionality of Expansion Coercive But......... Supreme Court fashions a “remedy” to overcome the coercion

6. Constitutionality of Expansion 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

7. Supreme Court on ACA’s Medicaid Expansion

8. 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

9. Past: Establishment of Medicaid

10. 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

11. Past: Medicaid Establishment 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

12. Past: Medicaid Establishment TennCare Medicaid 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

13. Present: Tennessee without Medicaid Expansion

14. Present: Tennessee without Medicaid Expansion Current source of Tennesseans HealthCare coverage

15. Present: Tennessee without Medicaid Expansion Tennessee Compared to United States

16. 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)

17. Future: Medicaid Expansion

18. Future: Medicaid Expansion • Means that Tennessee can extend TennCare coverage to individuals up to 138% FPL

19. Future: Medicaid Expansion • No deadline by which states must decide whether to expand or not • No partial expansion- all or nothing • Effects of expansion

20. Future: Medicaid Expansion Effects of Expansion • Effect on people below 100% FPL

21. Future: Medicaid Expansion Effects of Expansion

22. Future: Medicaid Expansion Effects of Expansion • Effect on people below 100% FPL • Financial Effects of Expansion

23. Financial Effects of Expansion Federal Government will pay Tennessee’s Increased Costs • 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

24. Future: Medicaid Expansion Effects of Expansion • Effect on people below 100% FPL • Financial Effects of Expansion • Effects of the Eligible but not Enrolled (EBNE)

25. 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

26. Future: Medicaid Expansion Effects of Expansion • Effect on people below 100% FPL • Financial Effects of Expansion • Effects of the Eligible but not Enrolled (EBNE) • Effects on healthcare availability

27. 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

28. Future: Medicaid Expansion Where do States stand on Expansion?

29. Where do states stand?

30. Medicaid Expansion?