Could people who lose Medicaid coverage get ACA plans?

The North Carolina Senate budget would reduce the Medicaid eligibility for aged, blind and disabled beneficiaries who qualify due to being medically needy–meaning they have high health care costs but their income would otherwise be too high.  It is difficult to say for sure how many persons would be effected because the budget lays out a principle–get eligibility as low as allowable under federal law. But here is a ball park estimate in terms of number of persons who could lose eligibility: of the ~54,000 medically needy persons in 2010, at a cost in 2010 of around $900 Million (I estimate that around 32,000 of them are aged or disabled (with blind mixed into disabled). I don’t believe children or adults are included in the proposal.

These are obviously expensive Medicaid beneficiaries on the whole, but the groups that would be targeted by this change are particularly expensive on a per capita basis:

ScreenHunter_04 May. 30 17.17

According to WRAL via their @NCCapitol twitter account, this afternoon on the Senate floor, Sen. Hise said that these persons being cut from Medicaid can buy insurance on the ACA exchange so they don’t need Medicaid. Is this true?

I believe this is false for some persons losing coverage, but true for others. And for some who could get coverage, the ACA benefit package–as expansive as it is–would not cover the Long Term Care Services that are so expensive for these persons. Lets walk it through.

  • The 21,500 elderly persons who are medically needy are not eligible for ACA plans. Anyone who is age 65 and over cannot buy health insurance in the ACA marketplace. They have Medicare for acute care services, and Medicaid due to high expenses as compared to income. From a recent Kaiser Family Foundation brief on the medically needy (p1):

Elderly living in nursing homes and children and adults with disabilities who live in the community and incur high health care costs comprise a large portion of spending in the medically needy program.

I believe that Senator Hise and others are misinformed.

  • The 10,100 disabled and blind persons younger than age 65 are eligible for ACA plans sold in the marketplace. However, there is a good chance that most of the care they are receiving via Medicaid won’t be covered by an ACA exchange plan because Long Term Care services are not typically covered by acute care insurance (or Medicare). That is why Medicaid has gotten involved in the first place.  Consider the figure below from KFF on the types of care that the medically needy receive:

ScreenHunter_05 May. 30 17.40

Part of the care costs of the 10,100 disabled and blind persons who would lose coverage could get some of their expenses covered by ACA plans, lets say one-third as a ball park estimate. However, two-thirds of these costs will not be met because acute care insurance doesn’t cover Long Term Care.

Bottom line: it is false that all persons who lose Medicaid under the Senate proposal will be able to be covered by an ACA plan. The elderly are not eligible. And for the blind and disabled who are younger and who could get coverage, the acute care plans sold on the exchange (and provided by Duke as a benefit of employment, for example) don’t cover Long Term Care. There seems to be a fairly large error behind the logic of this aspect of the Senate proposal.

If you think I have made an error above, let me know. It would of course be nice to have more detailed information about this sort of proposal–it is knowable with precision–including what type of care is being paid for by Medicaid and whether it would be covered under an ACA plan.

This is a bad day for my beloved North Carolina.

About Don Taylor
Professor of Public Policy (with appointments in Business, Nursing, Community and Family Medicine, and the Duke Clinical Research Institute), and Chair of the Academic Council at Duke University . I am one of the founding faculty of the Margolis Center for Health Policy. My research focuses on improving care for persons who are dying, and I am co-PI of a CMMI award in Community Based Palliative Care. I teach both undergrads and grad students at Duke. On twitter @donaldhtaylorjr

2 Responses to Could people who lose Medicaid coverage get ACA plans?

  1. Pingback: Long Tem Care Not Included in ACA Plans | freeforall

  2. Pingback: Medicaid reform in North Carolina | freeforall

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