Washington and the ACA’s Medicaid expansion

Washington state expanded Medicaid (Apple Health) in accordance with the Affordable Care Act (ACA), utilizing federal funding to provide health insurance for the newly-eligible population. In 2017, the state began to pay a very small portion of the expense. The state pays 6 percent of the cost in 2018, will pay 7 percent in 2019, and 10 percent after that. The federal government will continue to pay 90 percent of the cost of Medicaid expansion indefinitely, as long as the ACA remains intact.

As a result of Medicaid expansion, total enrollment in Washington Medicaid and CHIP grew by nearly 644,000 people between the fall of 2013 and November 2017. That was an enrollment growth of 58 percent, the sixth-highest percentage increase in the nation. The national average growth in Medicaid/CHIP enrollment was 29 percent, although that includes the 19 states that have not expanded their Medicaid programs under the ACA.

Amid concerns in 2017 that there might be areas of the state with no insurers offering plans for 2018, lawmakers in Washington introduced HB 2232, which would allow people in counties without available exchange plans to purchase Apple Health coverage instead. All counties in Washington did end up having insurers offering exchange coverage for 2018, but the bill was reintroduced in January 2018 as it was still unclear how robust exchange participation would be in future years.

Who is eligible?

In addition to the aged, blind, and disabled, Apple Health Medicaid is available for these Washington residents:

• Adults with incomes up to 138 percent of poverty
• Children with household incomes up to 200 percent of poverty are eligible for no-premium Medicaid
• Children with household incomes between 200 and 300 percent of poverty are eligible for Medicaid with a premium (the cap is $60 per household per month).
• Pregnant women with incomes up to 185 percent of poverty.
• Children are eligible for CHIP with household incomes up to 312 percent of poverty.

Apple Health for Kids is available to children even if they are undocumented immigrants. In that case, only state Medicaid funds are used to provide coverage, and families with income above 200 percent of the poverty level will have to pay higher premiums to cover a child who is undocumented. Pregnant undocumented immigrants are also eligible for state-funded Apple Health coverage.

How do I apply?

In Washington state, all Medicaid applications now go through the state-run exchange, Washington Healthplanfinder, unless you’re applying for Medicaid to pay long-term care expenses or help cover Medicare costs. Unlike private health plans, Medicaid enrollment continues year-round; there is no specific time during the year that you must enroll.

One of the benefits of the streamlined exchange application process is that it’s dramatically expedited compared with the pre-2014 enrollment system.  The state notes that eligibility determination in the past took about 45 days, and they now take about 45 minutes.

How many people have enrolled?

Washington Healthplanfinder released a report that detailed their first two years of enrollment (October 2013 through September 2015). During that time, they enrolled more than 1.4 million people in Apple Health, although net enrollment grew by a smaller amount due to changes in enrollees’ circumstances that result in people transitioning off the program throughout the year.

Since the exchange is handling all of the state’s Medicaid enrollments, their enrollment count includes new enrollees as well as renewals processed for people who already had Medicaid prior to 2014.

From late 2013 to August 2015, total net enrollment in Washington Medicaid and CHIP grew by about 613,000 people.

In July 2013, Washington was predicting that their Medicaid population would increase by about 325,000 people over several years as a result of the expanded eligibility guidelines. After four years of expanded eligibility, net enrollment growth is approaching 200 percent of that original projection—there are almost 644,000 more people enrolled in Medicaid/CHIP in Washington than there were in 2013. Not all of those people became eligible as a result of Medicid expansion, but it’s clear that the initial projection was low. But the growth in Medicaid enrollment has leveled off. It grew by about 613,000 people in the first two years, but has only grown by about 30,000 people since then.

Profound impact on uninsured rate

According to US Census data, the uninsured rate in Washington was 14 percent in 2013, and had fallen to 6 percent by 2016 — a drop of 57 percent. Only eight states had a higher percentage point drop in uninsured rate during that time, and Washington’s drop was far higher than the 5.9 percentage point drop across the country as a whole. It’s clear that Medicaid expansion has played a significant role in reducing the uninsured rate in the state.

But there is still work to be done. According to Kaiser Family Foundation data, there were still 621,000 uninsured residents in Washington, and 38 percent of them were eligible for Medicaid. And of the 75,000 uninsured children in the state, most were eligible for Apple Health for Kids, although their parents may not be aware of their eligibility.

The decision to expand Medicaid

Washington was one of five states that utilized a provision in the ACA that allowed for early expansion of Medicaid, prior to 2014.  As of 2011, Washington was using a waiver from CMS to allow for federal funding to cover adults with incomes up to 133 percent of poverty. Prior to 2011, Washington had covered these residents under the state-run Basic Health Plan, but that was funded by the state. Switching to early Medicaid expansion and accepting federal funding for this population was an obvious choice for the state.

As a gubernatorial candidate in the fall of 2012, Democrat Jay Inslee expressed his support for Medicaid expansion, and he won the election that November. Soon after Inslee took office, he was encouraging lawmakers to move “quickly” to expand Medicaid.

Rather than take a formal vote on the issue however, Medicaid expansion was added as a line-item to the state budget (with bipartisan approval), and on June 30, 2013, Washington Governor Jay Inslee approved the budget for the upcoming fiscal year.

Eligible residents were able to begin submitting applications on October 1, 2013, with expanded Medicaid policies effective January 1, 2014.

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Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

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