Health Care

Medicaid expansion could crowd out disabled

May 8, 2019

Ray Carter

Like many states, Oklahoma has a waiting list for people with developmental disabilities to receive services through a Medicaid waiver program. The waiver program funds home- and community-based services for people who would otherwise require institutional care, such as those with severe intellectual disabilities, traumatic brain injuries, spinal cord injuries, and mental illnesses.

Arkansas state Rep. Josh Miller warns that those individuals may be among the people most harmed, indirectly, by expanding Medicaid to able-bodied adults.

“It’s really disheartening when you see folks with severe needs and, at best, they have to wait several months to even a year or more to get services,” said Miller, R-Heber Springs. “And yet if you’ve got an able-bodied individual that’s between 18 and 65, they can walk right in and get signed up for free insurance.”

Under the traditional Medicaid program, states like Oklahoma receive roughly 60 cents in federal money for every 40 cents provided in state funding to give government health coverage to certain low-income and disabled individuals. But under the federal Affordable Care Act, better known as Obamacare, states receive a 90-10 match to cover able-bodied adults with income above the current eligibility threshold.

This year, Oklahoma lawmakers have considered legislation to expand Medicaid in Oklahoma, and an initiative petition has been filed to put expansion on the ballot and make it a constitutional right. It is estimated expansion could add 628,000 able-bodied adults to state welfare rolls and cost Oklahoma taxpayers $374 million annually.

Despite the high federal match, Miller said Arkansas legislators soon struggled to pay the costs of that state’s Medicaid expansion. The Arkansas plan uses federal Medicaid dollars to purchase private insurance, which Miller said “has been the most expensive and horrible way of expanding Medicaid.” Independent reviews have shown the Arkansas model is much more expensive than traditional Medicaid.

Arkansas’ Republican-controlled Legislature was not eager to embrace tax increases to pay for the expansion program’s costs, Miller said. That required lawmakers to instead shift funds from other priorities, and services at the state’s Department of Human Services became a favored target because they did not have political constituencies comparable to other areas of government spending.

“You start looking around the budget, what are you going to cut?” Miller said. “You’re not going to be able to cut higher ed and you’re not going to be able to cut K-12, and you certainly can’t cut the highway department. So you have to start cutting things within DHS.”

According to the Oklahoma Department of Human Services, there were 5,672 people on Oklahoma’s waiting list for developmental disabilities services as of March 31. Some of those individuals have been on the list since 2006.

The wait for services is so long that many give up. A 2015 report from Oklahoma Watch revealed that about half of those removed from the list in prior years had come off “after the department was unable to make contact with them.”

In 2018, the problem reached the point where members of the Oklahoma House of Representatives formed a Waiting List Caucus. A DHS spokesperson said about 100 people can be taken off the list and provided services for every $1 million in additional funding provided. Last year lawmakers provided another $2 million to help some people on the list.

Arkansas faces similar challenges, but Miller said people on that state’s waiting list were effectively deprioritized in the search to free up cash for Medicaid expansion costs.

“They’re having to cut things in order to come up with several million dollars to pay for Medicaid expansion,” Miller said. “At the end of the day, it’s still your most vulnerable and your most needy populations that are getting the shaft in order to pay for able-bodied, working-age adults, many of whom are not hitting a lick at a snake.”

A 2018 report from the Foundation for Government Accountability estimated that about 650,000 individuals were on Medicaid-waiver waiting lists nationwide with about 250,000 residing in Medicaid-expansion states.

In most states, the foundation noted enrollment in Medicaid-expansion programs far exceeded projections, which increased the amount of state funding required. Critics note all state money spent on the expansion population is cash that could have otherwise gone to those on the waiting list for disabilities services.

Today, Medicaid programs in many states are “enrolling a record number of able-bodied adults who are consuming limited resources,” the foundation report stated. “As these adults consume more and more resources, the truly needy are being left behind, many of them dying before ever getting the additional services they need.”

Former Rep. John Enns, an Enid Republican who served until 2018, agrees those on the waiting list need help, and worries Medicaid expansion will divert money away from them.

“The Medicaid waiver for these seriously disabled people is something we need to figure out how we can fund,” Enns said. “But I don’t believe that Medicaid expansion is the way to do it.”

Even with the federal government covering much of the cost of expansion, he noted the state share is still “money we’re going to have to come up with” and there may be better uses for that cash.

Enns believes the fact Oklahoma doesn’t cover the cost of helping people on the waiting list today, when the state isn’t trying to find another $374 million for Medicaid expansion, doesn’t bode well for those on the waiting list after expansion occurs.

“I worked with them as a representative, trying to get them funded properly,” Enns said, “but it was hard.”

Supporters of Medicaid expansion dismiss those concerns.

Mary Beth Musumeci, associate director for the Program on Medicaid and the Uninsured at the Henry J. Kaiser Family Foundation, has written that there is no “relationship between a state’s Medicaid expansion status” and the number of people on a state’s waiting list. However, Musumeci’s analysis does not directly address critics’ argument that the state cost of expansion leaves less money for helping those on the waiting list.

Musumeci also concedes “most people” on waiver waiting lists “are receiving other Medicaid services.” As a result those individuals, who critics say are not receiving the support they need today, would get no benefit from Medicaid expansion funds, which cannot be used for those already on the program.

Enns and Miller have a better understanding than most people of the plight of those on waiting lists. An accident left Enns in a wheelchair, although he never had to rely on Medicaid. Miller became a quadriplegic in 2003 at age 22 and did receive temporary help through a Medicaid waiver program.

Enns also knows people who have been on the waiting list for some time.

“These people, they need help,” Enns said. “Some people are voluntarily taking care of people and they’re trying to work besides. It’s a mess.”

In Arkansas, Miller says there’s less support available today to people like himself than what was provided when he was injured.

“As far as somebody with a disability, I’ve lived that experience from a consumer standpoint,” Miller said. “I can empathize and sympathize with folks who’ve gotten injured or hurt or whatever more recently. And they’re having difficulty getting the same programs that were available to me that allowed me to get back to living and get back in the workforce.”