Medicaid Expansion in Nebraska: Addressing Socioeconomic Inequities

• Publication year: 2022

52 Creighton L. Rev. 411. MEDICAID EXPANSION IN NEBRASKA: ADDRESSING SOCIOECONOMIC INEQUITIES

MEDICAID EXPANSION IN NEBRASKA: ADDRESSING SOCIOECONOMIC INEQUITIES

MOLLY MCCLEERY ^[*]

I. INTRODUCTION

In November 2018, Nebraska voters passed Initiative Measure No. 427 to expand Medicaid coverage in Nebraska. ^[1] Medicaid expansion will provide health insurance to nearly 90,000 low-income Nebraskans. ^[2] Often, these 90,000 Nebraskans are referred to as stuck in "the coverage gap," meaning they are ineligible for Medicaid but do not make enough money to qualify for premium tax credits on the Health Insurance Marketplace to make insurance affordable. ^[3] States that have not expanded Medicaid generally "have no eligibility for childless adults who are not disabled, and mandatory coverage levels for parents are very low." ^[4] The lack of coverage available for childless adults and very low eligibility levels for parents result in "significant inequities in adults' Medicaid income eligibility nationwide" that "lead to disparities in the rate of uninsured adults." ^[5] By expanding Medicaid to cover those traditionally unserved by Medicaid and the private insurance market, Nebraska is taking a significant step forward in addressing socioeconomic inequities in the state.

II. MEDICAID EXPANSION

The Patient Protection and Affordable Care Act ("ACA") included reforms designed to increase insurance rates among Americans with low and middle incomes, including the Health Insurance Marketplace, its premium tax credits, and an expansion of Medicaid coverage. ^[6] The ACA's Medicaid expansion extended coverage to adults between the ages of nineteen and sixty-four years old with incomes under 133 percent of the Federal Poverty Level ("FPL"). ^[7] Adults covered by the ACA's Medicaid expansion are individuals not otherwise eligible for Medicaid as a result of pregnancy or disability. ^[8] Since individuals must have an income of at least 100 percent of the FPL to access premium tax credits on the Health Insurance Marketplace, Medicaid expansion serves those whose incomes are below the level needed to purchase affordable insurance on the Marketplace. ^[9]

In 2012, the United States Supreme Court heard two challenges to the ACA's constitutionality in National Federation of Independent Business v. Sebelius. ^[10] Specifically, the Court ruled on the constitutionality of the individual mandate provision and Medicaid expansion. ^[11] The Court upheld the constitutionality of the individual mandate. ^[12] However, it determined the Medicaid expansion exceeded Congress's power under the Spending Clause and effectively rendered it an option for states rather than a mandatory program. ^[13] Despite that decision, as of November 2018, thirty-six states, including Nebraska, and Washington D.C., had opted into Medicaid expansion. ^[14]

III. WHO WILL BE COVERED BY MEDICAID EXPANSION IN NEBRASKA?

On November 7, 2018, Nebraska voters passed Initiative Measure No. 427, a general election ballot measure to expand Medicaid. ^[15] Medicaid expansion will cover two main groups of Nebraskans: low-income parents whose incomes are too high for traditional Medicaid and low-income, childless adults. ^[16] Traditional Medicaid in Nebraska covers low-income parents up to 58% of the FPL. ^[17] In 2019, 58% of the FPL is $1,031 per month for a household of three. ^[18] Medicaid expansion will cover parents with incomes over that 58% FPL eligibility cap up to 138% of the FPL, ^[19] or $2,390 per month in 2019 for a household of three. ^[20] Additionally, childless adults with incomes between 0% of the FPL and 138% of the FPL will be eligible for Medicaid. For a household of one in 2019, 138% of the FPL is $1,396 per month. ^[21]

The data available regarding those who will be eligible for Nebraska's Medicaid expansion demonstrate the benefits the new program could have statewide for low-income, working Nebraskans. The program would be particularly impactful in providing a source of coverage for uninsured individuals in Nebraska's rural areas. ^[22] Nearly a quarter of Nebraskans in rural areas are uninsured and have incomes below 138% of the FPL, meaning they would be eligible for Medicaid expansion. ^[23] This is higher than Nebraska's metro areas, where 19% of individuals are uninsured and have incomes below 138% of the FPL. ^[24] Most states that have expanded Medicaid have reduced the discrepancy in insured rates between metro and rural areas through adopting the program. ^[25]

Medicaid expansion is a program that will support Nebraska's low wage workers. ^[26] Of the Nebraskans who would be eligible for Medicaid expansion, the majority, 70%, are employed. ^[27] Of the remaining 30%, over half are individuals with disabilities, students, non-working spouses, retirees, and young adult dependants. ^[28] The remainder are individuals classified as unemployed. ^[29] Individuals in the coverage gap hold occupations that form the backbone of Nebraska's economy, including food service, construction, and sales, amongst others. ^[30]

IV. MEDICAID EXPANSION'S ROLE IN ADDRESSING SOCIOECONOMIC INEQUITIES

Medicaid expansion in Nebraska has the potential to reduce socioeconomic inequities through increasing access to care and improving health outcomes for low-income Nebraskans. Individuals without insurance "are likely to under consume medical services," meaning they delay preventive care and screenings, do not purchase prescribed medication, and defer health care for financial reasons. ^[31] However, "[a] large body of research points to expansion-related improvements across a wide range of measures of access to care and utilization of medications and services" across states. ^[32] One example of a state that has seen notable improvements in access to care and preventive services utilization through Medicaid expansion is Kentucky. ^[33] Data from the Kentucky Department of Medicaid Services from the first two years of the program show a large increase in the number of Kentuckians accessing preventive care. ^[34] Kentuckians enrolled in Medicaid were significantly more likely to access physical and dental exams and cancer screenings after Kentucky expanded Medicaid. ^[35] Specifically, between 2013 and 2014, the number of Kentuckians enrolled in Medicaid that had cancer screenings increased dramatically; breast cancer screenings went up 111%; cervical cancer screenings went up 88%; and colorectal cancer screenings went up 108%. ^[36] Additionally, preventive dental checkups rose by 116%, and physical exams increased by 187%. ^[37] Kentucky is just one example of the strides states have seen in access to care after expansion. ^[38]

It is also projected that Medicaid expansion will have benefits for the behavioral health of Nebraskans in the coverage gap. ^[39] Researchers from the United States Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation analyzed data from 2010 to 2014 and found that 31.6% of uninsured Nebraskans between the ages of eighteen and sixty-four with incomes below 138% of the FPL had a mental illness or substance use disorder, compared to 26.2% of the state's full population. ^[40] However, only 14.1% of uninsured individuals between the ages of eighteen and sixty-four received treatment for mental illness or substance use disorder. ^[41] Looking specifically at 2014 data, the researchers found that 21,000 Nebraskans who would have been eligible for Medicaid expansion had experienced a mental illness or substance use disorder in the past year. ^[42] It is...