ACA Open Enrollment Starts

Open enrollment through the Affordable Care Act starts tomorrow (November 15, 2014) and runs through February 15, 2015.  Here is a map updated in October for which states are providing their own health insurance exchanges and which are relying on the Federal www.healthcare.gov.  For the initial 2013-2014 enrollment period, the state exchanges outperformed the Federal exchange generally with Kentucky's KYNect being the star of the show.

Updated Medicaid Expansion Map

This map shows which states have taken up the Affordable Care Act's (ACA) opportunity to expand each state's Medicaid program to citizens earning 101-135% of the Federal Poverty Limit (FPL).  The majority of states and DC are now participating with the Federal government picking up the entire tab for the expansion for the first year or so.  Then the states will after a few years have to pay for 10% of the expansion and the Federal government will continue to pay 90% of the tab.

Several key points:

• If you are like me and live in a state whose governor and legislature has chosen not to expand Medicaid insurance, then you and your fellow citizens are paying taxes into the Federal government to support the expansion, but your state is not getting any of the direct benefits.

• By some estimates 8 million uninsured Americans were eligible for their states' Medicaid programs but were unaware or at least not enrolled.  The media attention and efforts to sign people up for insurance, however, may be providing the indirect benefit of getting more people to sign up for Medicaid who are eligible.

• The ACA was designed for all the states to expand Medicaid to the poorest uninsured.  People earning <101% of the FPL were already eligible for Medicaid.  Those earning >135% up to 400% of the FPL get a subsidy to help them pay for private insurance purchased through the health insurance exchanges.  Everyone must by law have insurance.  So in states that did not expand Medicaid, these poorest of the uninsured must by law purchase insurance but do not get Medicaid ...and they get no subsidy.  They are trapped in the "Medicaid donut hole" as some are calling it.

The ACA: Health Rankings and Health Exchanges

Most of the least healthiest states' governors opted to not pursue a state-level health exchange.

Of the 12 unhealthiest states in 2012, only one -Kentucky- opted to set up its own state health exchange under the Affordable Care Act.  Arkansas and West Virginia chose to set up joint Federal-state exchanges. All three states had Democratic governors in 2012.  

One other state in the bottom quarter of health rankings also had Democratic governor in 2012.  Missouri voters in 2012, however, passed a law blocking their governor from setting up a state health exchange. 

The other 8 unhealthiest states currently have Republican governors.

These maps underscore the political element involved in decisions to expand health insurance to the states with the most serious health challenges.

The ACA: Health Exchanges

Whether your state has its own health exchange or relies on the troubled Federal exchange, healthcare.gov, depends largely on whether you have a Democrat or Republican as governor.

History is full of ironies.  

Most Americans get their medical insurance from their employers.  This system is largely a fluke of history.  1930s Depression Era laws limited the ability of American employers to give raises.  So when the economy began to boom during and after World War II, employers turned to offering benefits as a way to recruit and retain workers.  In other countries, health insurance coverage usually evolved in the post-war, mid-20th century as a government service like the military, police, schools, and fire departments.  

For the US, 1965 was a crucial year.  It was in this year that Medicaid and Medicare started as programs to help certain groups of uninsured Americans.  By 2010 the public health insurance landscape in the US had become a patchwork of programs:

• Medicare for seniors
• Medicaid for low income Americans -mostly seniors and children
• VA (Veterans Administration) for military veterans
• TRICARE for active duty military and their families
• CHIP (Child Health Insurance Program) for low income children
• IHS (Indian Health Service) for Native Americans living on reservations

Ideas for how to cover the big group -the working poor- left out by these programs goes all the way back to the Nixon administration.  Ironically, largely Republican think tanks and policy experts created a system of funneling the uninsured into private health insurance programs using subsidies for the poor and individual mandates to require younger, healthier, uninsured people to buy private health insurance.  It was this basic program which Republican Governor Mitt Romney installed in Massachusetts.  And it is this system of using private health insurers and government subsidies which is the same model making up Obamacare.

Even more irony:  More liberal Democrats wanted to simply expand Medicaid to cover the uninsured and have a tax withdrawn from people's checks in the way we pay for Medicare.  Some political commentators argue the use of the Romneycare model -plus the adoption of more than a 100 Republican amendments to the ACA- largely was a failed carrot to entice Republican legislators to vote for the ACA.  So, while the ACA is largely a Republican idea filled with Republican amendments, the ACA passed with zero Republican votes in 2010.  

Thus, it comes as no surprise that most Republican governors have opted to not set up a health exchange for their state and instead let the Federal exchange fill the void.

The Affordable Care Act (ACA): Obamacare Comes to America

Congress enacted the Affordable Care Act -AKA Obamacare- in 2010.  Various elements of the new healthcare law have been rolling out in the past several years, but the key health exchanges opened this month.  My next series of maps and data will focus on the ACA.

If you are interested in my own personal odyssey enrolling for coverage, check out one of my other blogs, My ACA Experience.