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Memorandum

Date: April 1, 2019.

To: Representative David Bairea, Minority Leader, House of Representatives.

From: 76867F Legislative Policy Analyst

Re: Expanding Medicaid In Mississippi

Introduction

The purpose of this memorandum is to explore ways to expand Medicaid in Mississippi.

A large number of Mississippians (BRFSS 2012) have neither private healt h insurance nor

Medicaid coverage. Medicaid has offered millions of Americans medical coverage since its

launch in 1965. When given the opportunity to expand Medicaid, some states have refused to

implement this expansion. According to Patient Protection and the Affordable Care Act (ACA),

(2010) “an estimated 2.2 million Americans who are not insured across the country fall in the

‘coverage gap’, apparently made up of people who are too poor to qualify for tax credits but

cannot access this discounted medical service because their state has not undertaken to

implement the Medicaid program as provided for under ACA” (Garfield et al., 2016, p. 2).

In 2018, Mississippi was among the 17 states that had not expanded Medicaid. Although

the number of states where Medicaid expansion has not occurred has been on the decline in the

last five years, there is a significant concern that in non-expansion states, many residents are

lacking access to affordable medical care services.

Medicaid has proven significant in boosting access to healthcare services, especially for

the low-income earners. Despite sufficient evidence on the impact of affordable healthcare

insurance to the middle and low-income earners, Mississippi remains reluctant to expand its

Medicaid program (Garfield et al., 2016, p. 2). Per your request, I have presented three policy

change options that could expand Medicaid in Mississippi.

Assessment of the Problem

As of the end of 2018, without Medicaid expansion, Mississippi had at least 221,000 low-

income medically uninsured adults. Of these, 64 percent – at least 134,000 Mississippi residents

were African-Americans (Stoll, 2015, p. 1). The ACA encourages states to extend affordable

healthcare coverage to individuals who earn not more than 138% of poverty income level, (up to

$28, 676 for a family of three), by providing federal funds to cover up to 90% of the cost.

Despite this financial incentive, Mississippi has not expanded its Medicaid program.

Data from the U.S. Centers for Disease Control and Prevention’s Behavioral Risk Factor

Surveillance System (BRFSS 2012) shows that uninsured, low-income earning Americans of

African descent are more likely not to see a healthcare physician or doctor even after suffering

mild illnesses due to lack of sufficient funds, and more likely to miss routine annual healthcare

check-ups more often than insured people (Akinyemiju et al., 2016, p. 197). Further analysis

shows a close correlation between Medicaid expansion and improved access to healthcare

services. Akinyemiju et al., (2016) found that not seeing a doctor for cost reasons was more

apparent for uninsured low-income earners (66%) than for insured low-income earners (25%)

(Akinyemiju et al., 2016, p. 198). For achieving the typical routine check-ups, 40 percent of

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uninsured low-income earners could not meet the cost of seeing a physician or a doctor for

routine check-up against 21 percent of those insured (Akinyemiju et al., 2016, p. 197).

The enactment of the Affordable Care Act of 2010 expanded coverage of Medicaid to

more adults with low incomes. The ACA eligibility for Medicaid for non-elderly adults was

moved from an income ceiling of $11,880 to $16,394 for an individual – 138% of the federal

poverty level (Akinyemiju et al., 2016, p. 197). In 2012 the Supreme Court decision (BRFSS

2012) determined that Medicaid expansion was optional for states. While 33 states, as of 2017,

had chosen to accept the federal funding for health coverage of a much larger group of low-

income earners, Mississippi and 16 other states did not accept Medicaid expansion.

Action-Forcing Event

Event Problem

 Lack of access to Medicaid

insurance.

 Inability of the state government

to offer affordable healthcare

insurance services to low-income

earners.

 Increasing the cost of healthcare,

making it inaccessible to low-

income earners.

 Can affordable healthcare

insurance be implemented?

 Is the current policy framework

sufficient to offer a solution to

this problem?

 Need to accept Medicaid funds

from the federal government?

Literature Review

This section outlines the literature related to the expansion of Medicaid across the

country. It draws on the evidence-based facts about the benefits of Medicaid expansion

programs. Lambrew and Mishory (2018, p1) note that numerous lessons should be learned from

the past fifty years’ experience "to provide medical assistance to individuals whose income and

resources are insufficient to meet the costs of necessary medical services' (Lambrew and

Mishory 2018). Garfield et al. (2016, p.3) note that in the 17 states with no Medicaid expansion,

an estimated five million uninsured people, mainly comprised of poor and low-income earning

working class people remain without healthcare. Also, some people with slightly higher incomes

earn in excess to qualify for Medicaid but are also too great to qualify for Marketplace premium

tax credits

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Empirical evidence Stoll, (2015) suggests a strong correlation between expansive access

to healthcare insurance and improved health status and outcomes. Insurance coverage makes it

possible for healthcare seekers to access medical doctors, meet their hospital bills and thus be

able to access treatment as needed. Lambrew and Mishory (2018) noted that individuals with

health insurance coverage tend to have doctors and health physicians at their disposal for routine

and regular healthcare check-ups anytime they need medical attention. This makes it possible for

early detection and treatment of any illness or condition affecting the insured, largely serving to

protect them against suffering from any escalated or adverse and costly illness.

The Council of Economic Advisers (CEA) 2014 found that expanding Medicaid through

the ACA had positive economic implications stretching to economic and employment

perspectives. States that accepted Medicaid expansion had healthier populations and more money

to spend on non-medical programs. As reported by Dom, McGrath, and Holahan (2014 p. 6), an

average Medicaid expansion was expected to create at least 78,600 new jobs in the first year,

172,000 in the second year, and a further 98,200 jobs in the third year in the average state

(Crowley & Golden, 2014 p.424).

The ACA provides for each state’s sovereignty in selecting which Medicaid approach to

use in rolling out the program. In 2014, Wisconsin extended Medicaid to all adults below the

new ACA poverty level, specifically to even those adults without dependents (Gregory, Peacock,

and Parke -Sutherland, 2017 p.2). Wisconsin covers a more expansive population of citizens and

reportedly saved an estimated $1 billion by covering more people.

Almost all states’ approach to the adoption of the Medicaid program has greatly varied

based on healthcare needs factors, state law, and political factors. The Affordable Care Act

provides for each state’s sovereignty in selecting which Medicaid approach to use in rolling out

the program.

Wisconsin’s approach to the Medicaid program expanded the policy to cover all adults.

Thus, all Wisconsinites adults below the poverty level are eligible for Medicaid insurance.

Although under the provisions of the ACA people falling below the federal poverty level are not

qualified for inclusion into the program, Wisconsin’s approach has made it possible to acquire

such services for all adults in need of the services even if they do not have any parental

obligations. This expansion was instituted by the state in 2014, alongside the federal government

expansion plans (Gregory, Peacock, and Parke-Sutherland, 2017 p. 2). The state government for

that matter covers a more expansive population of citizens and reportedly saving an estimated $1

billion by covering more people.

South Carolina’s representative and lawmaking body have emphatically dismissed

Medicaid extension under the Affordable Care Act (ACA). Thus, there are around 92,000

individuals in the state who are in the inclusion gap with no reasonable access to medical

coverage. They are the state's least fortunate occupants, with salaries under the neediness level.

They don't meet all the requirements for appropriations in the trade, and they additionally don't

fit the bill for Medicaid. By and large, they depend on crisis rooms and network wellbeing

centers, yet future subsidizing for those facilities is in danger as well. Senator Nikki Haley (R) is

against Medicaid extension. No enactment has been acquainted in the present session with

expansion Medicaid (Blumenthal, and Collins, 2014).

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Given Florida's extensive generally populace, it additionally has a substantial Medicaid

populace — more than 4.2 million as of May 2018. Be that as it may, a family's salary must be

very low to fit the bill for the program. What's more, most grown-ups who don't have kids aren't

qualified for Medicaid in Florida, because the state hasn't acknowledged government subsidizing

to extend inclusion — in spite of the way that 68 percent of Florida occupants bolster Medicaid

extension. Governor Rick Scott (R) has been vocal in his resistance to expansion of Medicaid,

and Florida administrators voted against a Medicaid extension proposition back in June

(Blumenthal, and Collins, 2014). The 2016 authoritative session started January 12, and

legitimate specialists don't anticipate that Medicaid extension should be an outstanding issue in

the current year's session – even though HHS is proceeding with endeavors to get Florida to push

ahead with development. Starting in early February, no Medicaid expansion bills had been

presented in the Florida assembly.

Stakeholder Analysis

The stakeholders involved in dealing with Medicaid expansion in Mississippi are

Governor Phil Bryant, Senator Bruce Wiggins, Representative Chris Brown, Medicaid Director

Drew Snyder, Lobbyist 1 Tim Moore, and Lobbyist 2 Edward Miller.

Governor Phil Bryant can veto and sign bills into law. What does he think about

Medicaid expansion and what does he think about the three options? Bryant has reliably

restricted Medicaid development, and his correspondences executive, Earth Chandler, says

nothing has changed: "Gov. Bryant remains unyieldingly contradicted to Medicaid development

(Lambrew, 2018 p. 12)

Senator Bruce Wiggins is Chair of the Senate Committee on Medicaid and is in favor of

expanding Medicaid in Mississippi. He prefers which option? He inclines toward an

arrangement of enabling Medicaid to put 100 percent of its patients, including long haul care

patients who make up the best segment of the Medicaid spending plan, under the oversaw

consideration plans. The altered bill would frame an examination advisory group to look at this

choice, as well (Crowley, and Golden, 2014 p. 3).

Representative Chris Brown is Chair of the House Committee on Medicaid. What does

he prefer? Brown incline toward that the specialized revision bill should just include the certified

people for inclusion, and what inclusion they will be they offered as the recipients Lambrew,

2018 p. 65).

Drew Snyder is the Director of the Mississippi Division of Medicaid, and his department

has expertise in implementing the current Medicaid program. What does he prefer? He leans

toward improving all repayment rates, by limiting domineering authoritative prerequisites. He

likewise leans toward in no placement of extra for human services suppliers (Alker et al. 2014 p.

8).

Tim Moore, a lobbyist, is the Chief Executive Officer of the Mississippi Hospital

Association, and he prefers whatever option gives Medicaid insurance to the greatest number of

Mississippi residents. Hospitals need patients and prefer not to take care of uninsured patients.

Moore has been lobbying the legislature to expand Medicaid (Gregory et al. 2017 p. 6).

Edward Miller, the senior member and Chief Executive Officer of Johns Hopkins

Medicine cautioned that putting millions of additional individuals on Medicaid would mean

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pulverizing requests for Mississippi, which treat a substantial number of low-pay patients. He

cautioned that Mississippi Medicaid development could have calamitous consequences for the

individuals who give society's medicinal services wellbeing-net (Lambrew, 2018 p. 12).

Stakeholder Analysis Chart

Stakeholder Phil Bryant Bruce

Wiggins

Tim Moore

Chris Brown Drew Snyder Edward

Miller

Title/Functio

n

State

Governor

State

Senator,

Chair Senate

Committee

on Medicaid

CEO,

Mississippi

Hospital

Association

Representative,

Chair, House

Committee on

Medicaid

Director

Mississippi

Medicaid

Chief

Executive

Officer of

Johns

Hopkins

Medicine

Source of

Influence

Vetoes and

signs bills into

law

Introduces

and votes on

bills

Lobbyist Introduces and

votes on bills

Expertise Lobbyist

Explanation

of the

Problem

More people

need reliable

health

insurance

Hospitals need

a reliable

revenue

More people

need Medicaid

Decision-

makers will not

pass Medicaid

expansion

Health

Reform

Could

Harm

Medicaid

Patients

Perception of

Crisis

Crisis Crisis Huge Crisis Crisis Crisis Huge Crisis

Proximity to

Problem

Close Close Very close Close Very close Very Close

Ability to Fix

Problem

Able Able Not Able Able Not

Ends Desired Expand

Medicaid

Expand

Medicaid

Expand

Medicaid

Definition/

Measure of

Success

Reduce those

without

Medicaid to

25% of those

eligible

. No uninsured

patient

presents at

hospitals

. Availability of

adorable

services And

reliable health

insurance

coverage for

.

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residents.

Essential to

Solution?

Yes Yes No Yes Yes No

Observing the above stakeholder analysis implies a shared support for the

implementation of a reliable and affordable health insurance coverage for the residents of

Mississippi. Essentially, while the state legislature is in support of having such an affordable

health insurance coverage, there are concerns on the impact of the Medicaid program on the

quality of health care provided. The fact that all believe that affordable health insurance should

be in place implies a common support for this policy.

Options Specification

Alternative 1 offers the Medicaid extension just covering the protective covers and the

conventional inclusion of prescribed grounds according to the central government program

development plans. This plan aims to include people falling below the qualifications and availing

an affordable medical insurance cover to these people. They include groups like the people in

need of long term care, disabled, and low income earning parents who have parental obligations.

Alternative 2 includes a cost-sharing model where private insurance firms offer people

excellent human services protection covers. With this cost-sharing model, individuals that

qualify for this insurance pay a premium fee to access these insurance covers with the

government covering the other costs by compensating firms that give premium healthcare

insurance covers.

This policy recommends three policy implementation options for Medicaid expansion by

the Mississippi state government. Each of the three options offers some level of Medicaid

expansion improvements extending the reach of the health insurance coverage to more groups.

The three options are:

The first option, traditional Medicaid expansion gives Mississippi and different states the

choice to give Medicaid to inhabitants’ wages up to 138 percent of the government destitution

level ($32,913 for a group of four out of 2014). Twenty-seven states and the Locale of Columbia

have chosen to acknowledge the government dollars and extend Medicaid to their low-salary,

uninsured occupants.

The second option is modified Medicaid expansion, a family's pay must be close to 28

percent of neediness ($6,678 yearly for a group of four). Mississippi does not give any Medicaid

inclusion to grown-ups without dependent children. In certain states workers with earnings of up

to 100 percent of neediness are now qualified for Medicaid through discretionary Medicaid

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classifications and government waivers. In any case, the majority of the states looking for not to

grow qualification have progressively prohibitive qualification prerequisites.

The third option is augmented Medicaid expansion that doesn't extend their Medicaid

programs, individuals with livelihoods of 100– 138 percent of destitution will be qualified for

government endowments on the individual protection trades. The Affordable Care Act does not

permit individuals with salaries underneath 100 percent of neediness to get appropriations on the

trades. There is an exemption for ongoing outsiders, who are commonly not qualified for

Medicaid. However, without extended Medicaid inclusion, others in the least fortunate section of

the populace may need access to reasonable health care coverage.

Options specification

Options Option 1 Option 2 Option 3

Description of

Policy Change

Medicaid expansion

to cover up to 138%

of FPL.

Medicaid expansion to

cover all adults below

138% of FPL for all

those with parental

obligations.

Medicaid expansion to

cover all adults including

non-parental adults below

138% FPL.

Source of

Option Idea

Mississippi’s

Recommendations

of the ACA

Medicaid expansions

of 2014.

South Carolina approach

to Medicaid expansion.

Wisconsin’s approach to

Medicaid expansion

Implementation

Responsibility -

state agency

The state

government in

collaboration with

the federal

government and

Medicaid program

department.

State government State government

Mechanism of

Effect

Offer medical

insurance coverage

for those earning

within the bracket of

138% below the

FPL.

Include those earning

below 100% FPL but

have parental

obligations.

Include adults with and

without parental

obligations but earning

less than100% of FPL in

the cover.

Cost 10% state

government

contribution to the

Medicaid expansion

program.

20% state government

contribution to the

Medicaid expansion

program.

30% state government

contribution to the

Medicaid expansion

program.

Legal

Requirements

Approval by the

state government

and change of the

state healthcare

insurance law and

policy.

Approval by the state

government and change

of the state healthcare

insurance law and policy

Approval by the state

government and change of

the state healthcare

insurance law and policy

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Phil Bryant 

Bruce Wiggins 

Tim Moore 

Chris Brown 

Drew Snyder 

Degree of

Consensus

80 percent

There are slight differences in the views of the stakeholders regarding the type of policy

framework that best suits the interest of the people while fitting within the budget of the state

government. The state legislature is conservative on the implementation of a policy that will

cover all adults including those without parental obligations. Perhaps, this is related to the earlier

mentioned views that Medicaid does not correlate with quality of care in any way thus a

discouragement for proposing a robust policy framework.

Options Assessment

The options are assessed using five criteria: political feasibility, administrative

feasibility, financial feasibility, equity, and effectiveness.

Political feasibility – Commonly the individuals for the strategy examination will hold a

political office. All things considered, the strategy examiner should frequently incorporate

political criteria in the evaluation of proposed arrangement options. This analysis is used as a

prediction to the outcome from a specific problem by looking at the environment, events and

actors involved in policy making.

Administrative feasibility – Open offices execute numerous open approaches. In this

way, regulatory operability or authoritative straightforwardness are frequently utilized as criteria

for judging proposed accessible arrangements. The state law and tax system needs to be clear as

to what the citizens are to comply with while at the same time giving the least inconvenience to

the taxpayer.

Financial feasibility – this is a study to check the viability of the expansion. Capital

needed, returns on investment and sources of capital among other considerations are done. It will

consider the amount of money needed for the expansion and on what it will be spent on to

determine the best possible way to implement the expansion.

Equity– this is the proportion of progress yielded with this alternative. Equity of the

expansion will look at the distribution of benefits to the whole community regardless of their

ability to benefit from it and their situation.

Effectiveness- proficiency and viability are specialized and this analysis will look at the

limited resources allocated to the Medicaid expansion and find a way to best serve the

community irrespective of their earnings as it meets the communities’ healthcare needs.

Traditional expansion

While option 1 offers the Medicaid expansion only covering the insurance covers the

traditional coverage of recommended groups as per the federal government program expansion

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plans. The option seeks to ensure those falling within the coverage gap within Mississippi are

availed with an affordable medical insurance cover. As such it covers adults earning 138% of the

FPL, including low-income earning adults with parental obligations, disabled, and those in need

of long-term care.

Modified Medicaid Expansion

This involves a cost-sharing model where private insurance firms offer individuals

premium healthcare insurance covers. This option does not necessarily expand Medicaid but

requires that federal funds be used in compensating firms that offer eligible residents healthcare

insurance. However, these individuals pay a premium fee.

Augmented Medicaid Expansion

This stretches further beyond the traditional expansion by reaching out to those adults

who do not have parental obligations but in need of such insurance cover. Under this option,

Medicaid expansion will cover all adults including non-parental adults from 138% down to those

earning below 100% of FPL including low-income earning adults with parental obligations,

disabled, and those in need of long-term care.

Options Assessment

Options Traditional

Expansion

Modified Medicaid

Expansion

Augmented

Medicaid Expansion

Description of policy

change

Expansion to cover the

adults earning 138% of

the FPL

Medicaid expansion

to cover all adults

below 138% FPL,

with parental duties

Medicaid expansion

to cover all adults

including non-

parental adults below

138% FPL

Political Feasibility 3 2 1

Administrative

Feasibility

1 2 3

Financial Feasibility 2 1 3

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Recommendation

Traditional Medicaid expansion is the recommended choice of Medicaid insurance cover

based on the five feasibilities. It is politically feasible as the state left the decision to implement

the ACA to the States as more States and individuals are joining the Medicaid insurance

coverage. It is financially feasible as States which implement the ACA initiative will receive

100% matching from the government it cover costs for new enrollees. It is administrative

feasible as there are mechanisms and structures already in place for the current Medicaid

programs which can handle gradual expansion. This traditional Medicaid expansion will be

effective as benefits have been seen in other States as everybody who qualifies under federal law

can access these resources including adults with parental obligations. Though, there will be some

out of pocket costs for the people such as very minimal co-payments on prescriptions. The

benefits outweigh the minimal out of pocket costs for the people.

Equity (Government

to Individual

Contribution Ratio)

90:10

80:20

70:30

Effectiveness 1 2 3

Summary Ranking Total 1 Total 2 Total 3

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References

Akinyemiju, T., Jha, M., Moore, J. X., & Pisu, M. (2016). Disparities in the prevalence of

comorbidities among US adults by state Medicaid expansion status. Preventive

Medicine, 88, 196-202. doi:10.1016/j.ypmed.2016.04.009

Alker, J., Jordan, P., & Wagnerman, K. (2018). How Mississippi’s Proposed Medicaid Work

Requirement Would Affect Low-Income Families with Children. Retrieved April 1,

2019, from https://ccf.georgetown.edu/wp-content/uploads/2018/08/Propsed Medicaid-

Work-Requirement-Mississippi.pdf

Blumenthal, D., & Collins, S. R. (2014, July 17). Health Care Coverage under the Affordable

Care Act ? A Progress Report | NEJM. Retrieved from

https://www.nejm.org/doi/full/10.1056/NEJMhpr1405667

Crowley, R. A., & Golden, W. (2014). Health Policy Basics: Medicaid Expansion. Annals of

Internal Medicine, 160(6), 423-425. doi:10.7326/m13-2626

Garfield, R., Orgera, K., & Damico, A. (2019, March 21). The Coverage Gap: Uninsured Poor

Adults in States that Do Not Expand Medicaid. Retrieved from

https://www.kff.org/medicaid/issue-brief/the-coverage-gap-uninsured-poor-adults-in-

states-that-do-not-expand-medicaid/

Gregory, S., Peacock, J., & Sutherland, W. (2019, March 21). The Coverage Gap: Uninsured

Poor Adults in States that Do Not Expand Medicaid. Retrieved from

https://www.kff.org/medicaid/issue-brief/the-coverage-gap-uninsured-poor-adults-in-

states-that-do-not-expand-medicaid/

Lambrew, J., & Mishory, J. (2018, July 31). Closing the Medicaid Coverage Gap. Retrieved

from https://tcf.org/content/report/closing-medicaid-coverage-gap/?agreed=1

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Stoll, K. (2015). Expanding Medicaid in Mississippi: Unlocking the Door to Health Insurance

for African Americans. Retrieved April 1, 2019, from

https://familiesusa.org/sites/default/files/product_documents/MCD_Morehouse%20COC

%20HE%20report_MS_Black_final_web.pdf