I Have a Feeling We’re Not in Kansas Anymore

I commend to all of you Jagadeesh Gokhale's policy brief "Should Kansas Expand Medicaid Under the Affordable Care Act? A Perspective on Weighing the Costs and Benefits."  The most interesting part of his paper is where he compares current and projected Kansas adult Medicaid enrollment for what he calls old-law eligibles and the newly eligible.  Along the way, he notes that "[e]stimates for the number of currently eligible but not Medicaid-enrolled individuals range from 20,000 to 162,000 [citations omitted]" — a number that could actually exceed the estimates for potential new Kansas Medicaid enrollment from Medicaid expansion.  

The astonishing fact is that  currently Medicaid eligible adults in Kansas have a take up rate of roughly 50-60 percent. Once you compare that with Medicaid take up rates that exceed 70 or 80 percent in a state like Massachusetts, you have to ask the hard question about just how hard a state like Kansas has been working to enroll the currently eligible in Medicaid or, alternatively, how hard a state like Kansas may have been working to keep its Medicaid take up rate for elgibile adults at current levels.

As Sommers et al have noted in studying adult Medicaid take up rates, the more generous the coverage, the higher the enrollment rate. Beyond that, the use of asset tests is associated with lower take up just as the use of a common family application is associated with higher. Generosity matters. Hassle matters. But there is more to it than that.

Most interesting of all is the fact that Medicaid take up increased dramatically in Massachusetts after the implementation of state specific health care reform — not because some Massachusetts citizens were required to enroll in Medicaid. They were not. No, the fact that some thought they were obligated combined with the fact that others became educated about their eligibility to produce record high Medicaid take up rates for adults in Massachusetts.

So, when I read a report, like that authored by Jagadeesh Gokhale, indicating that the budgetary goal of keeping currently elgibile adult Medicaid take up from increasing, I wonder just what game is being played. Is it ACA sponsored Medicaid expansion that is, arguably, fiscally irresponsible or is it the ACA's Medicaid outreach to the currently eligible that is so troubling? And if developing a culture of coverage is fiscally inadvisable, why not just say that?

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