Who gets left behind by LePage and other health expansion opponents’ “alternative”?

Rep. Deborah Sanderson

Rep. Deborah Sanderson

Opponents of Medicaid expansion in Maine keep saying there is an alternative available to the people who would be covered under an expansion.

The purported alternative is that people who would receive Medicaid under an expansion can instead buy subsidized insurance through the marketplace.

For instance, Rep. Deborah Sanderson recently said on the radio that she told pro-expansion Mainers at the statehouse they could still get coverage if there’s no expansion. And in a recent op-ed, Sanderson claimed, “Forty thousand, or over half, of the 70,000 people that would be eligible for expanded Medicaid are eligible for these plans on the exchange.”

Unmentioned is who couldn’t get any health coverage, who would be left out

If Medicaid is not expanded in Maine, the poorest people who would have been covered by Medicaid expansion would not get any help at all. They would get no subsidies to obtain insurance. None. Zippo.

Medicaid expansion opponents would leave the neediest Mainers without insurance, getting less health care.

As the New York Times explained awhile ago:

Coverage for people earning below the poverty level was supposed to be handled by a federally funded expansion of Medicaid. But the Supreme Court ruled in June that expanding Medicaid was optional — and half the states chose not to do it, contending that the added costs would be too burdensome for taxpayers. The law didn’t anticipate the lack of Medicaid expansion, so there is a gap in coverage for those who don’t qualify for their state’s existing Medicaid plan, and who earn too little to qualify for financial help on the exchanges.

Moreover, Maine can’t cover our poorest people with Medicaid and have others eligible under expanded Medicaid just go ahead and buy subsidized insurance through the marketplace.

That’s because a state can’t cover just a portion of those who are eligible for Medicaid under the ACA.

Because of the Supreme Court’s decision, states can decide not to cover anyone who would be covered under Medicaid. But if a state covers some, it has to cover them all.

Gov. LePage

Gov. LePage

Some Medicaid expansion opponents, including Gov. LePage, keep suggesting otherwise. They say they’d be fine with an alternative that is not actually an option — covering some under Medicaid, with those not covered getting insurance through the marketplace.

But as this newspaper recently explained:

In a WGAN radio interview last month, the Republican governor said he would support legislation — if it existed — that provides Medicaid coverage to approximately 30,000 Maine adults without children whose incomes fall below the federal poverty level ($11,490 for a single person).

Anyone with a higher income, he reasoned, can and should enroll in subsidized, private insurance through the Affordable Care Act’s online insurance exchange, HealthCare.gov.

The problem — which LePage acknowledged — is that the Obama administration has made it clear to states that they can’t partially expand Medicaid and still qualify for the full expansion funding authorized in the federal health care law.

In other words, governors like LePage can’t stop the expansion at 100 percent of poverty; they have to expand it to everyone earning up to 138 percent of the poverty level (about $15,860 for a single person). [source]

For years, the federal government has been very clear that a state cannot partially expand Medicaid to just part of the newly Medicaid-eligible population.

Here’s some proof, from a 2012 article in the Washington Post:

The Obama administration told states Monday that they couldn’t do a partial expansion of Medicaid under the health-care law and still receive full federal funding, disappointing many Republican governors on one of the most important questions surrounding the health-care law.

More recently, South Dakota floated the idea of putting some people on the exchange rather than having them covered by Medicaid. Here’s how a paper from that state reported the idea:

Gov. Dennis Daugaard wants to expand Medicaid in South Dakota under the Affordable Care Act — but only part of the way, and only if the federal government lets him.

Daugaard, with support from legislative leaders in both parties, has sent a letter to federal Health and Human Services Secretary Kathleen Sebelius asking for permission to cover people earning up to 100 percent of the poverty line in the Medicaid program. The health care law calls for states to expand Medicaid up to 133 percent of the poverty line. . .

If Daugaard gets his way, people earning up to 100 percent of the poverty line — $11,490 for a single adult or $23,550 for a family of four — would be eligible to enroll in Medicaid. People earning between 100 percent and 133 percent of the poverty line could — as they can now — buy health insurance on the Affordable Care Act’s online exchanges and receive substantial subsidies to offset those costs.

Last year, Daugaard asked Sebelius informally if she would approve such a solution, and was told no.

See how that goes?

  • Expanding Medicaid means the state, using all federal dollars at first, covers everyone from under the poverty level to the upper limit of coverage. None of those people would buy their insurance through the marketplace. [The one exception would be if the state helps pay for private insurance, under a model called the “private option.” No one in Maine has proposed adopting this model.]
  • Not expanding Medicaid means that people at the federal poverty level or below get no help whatsoever in getting coverage. People above the poverty level can buy insurance through the exchange and get federal subsidies. This may still be difficult for these very poor people to afford.

Medicaid expansion opponents should be forthright that if there isn’t an expansion, the poorest Maine people won’t be able to get coverage. They can’t buy subsidized insurance through the marketplace.

In fact, the neediest of the Medicaid eligible would be left behind in the “coverage gap.” If Maine is to cover those folks, it has to cover everyone eligible under Medicaid expansion. (See this write-up from the Kaiser Family Foundation for a graph and more explanation.)

And the chance of this changing in the law is nil. It’s not only a more expensive approach to covering people, but House Republicans continue to vote to repeal the entire Affordable Care Act. Even if the president supported making this change, there is no way it could be enacted.


Technical note: You may be wondering why one source above says coverage goes to 133% of poverty, while another says it goes to 138% of poverty. The explanation has to do with the method of calculating income; see here for an explanation.

Amy Fried

About Amy Fried

Amy Fried loves Maine's sense of community and the wonderful mix of culture and outdoor recreation. She loves politics in three ways: as an analytical political scientist, a devoted political junkie and a citizen who believes politics matters for people's lives. Fried is Professor of Political Science at the University of Maine. Her views do not reflect those of her employer or any group to which she belongs.