health policy articles

Small Change, Big Consequences — Partial Medicaid Expansions under the ACA

Adrianna McIntyre, M.P.P., M.P.H., Allan M. Joseph, M.P.H., and Nicholas Bagley, J.D.

Though congressional efforts to repeal and replace the Affordable Care Act (ACA) seem to have stalled, the Trump administration retains broad executive authority to reshape the health care landscape. Perhaps the most consequential choices that the administration will make pertain to Medicaid, which today covers more than 1 in 5 Americans.1

Much has been made of proposals to introduce work requirements or cost sharing to the program. But another decision of arguably greater long-term significance has been overlooked: whether to allow “partial expansions” pursuant to a state Medicaid waiver. Arkansas has already submitted a waiver request for a partial expansion, and other states may well follow its lead.2

To understand Arkansas’s request, and why it matters so much, some background is in order. Medicaid waivers have long allowed states to experiment with delivery reform and coverage expansions, but waivers became more consequential in 2012, when the U.S. Supreme Court gave states a choice about whether to expand their Medicaid programs to cover everyone with an income of up to 138% of the federal poverty level. Some states sought greater flexibility to expand Medicaid on their own terms, which made participation in the expansion more palatable in Republican-controlled states. After intense negotiations, the Obama administration granted expansion waivers to seven states...

Full article published in The New England Journal of Medicine