Critics say states that expand Medicaid to include able-bodied adults often do so at the expense of people with severe physical challenges who now spend years on waiting lists to receive community-based services that prevent them from requiring institutionalized care. Home-and-community based care is an optional benefit under Medicaid, so states are allowed to ration those services, and many do.
The Henry J. Kaiser Family Foundation has pushed back against those critiques, claiming there is no “relationship between a state’s Medicaid expansion status” and the number of people on a state’s waiting list.
But Chris Jacobs, founder of the Juniper Research Group and a policy expert who has worked for several think tanks, says the Kaiser Foundation research has glaring methodological flaws that make its conclusions meaningless.
“This looks to be a political talking point in search of data,” Jacobs said.
In the analysis, Mary Beth Musumeci, associate director for the Program on Medicaid and the Uninsured at the Henry J Kaiser Family Foundation, wrote that the waiting list for community-based services for those with severe medical challenges increased from 2015 to 2016 in 13 states that expanded Medicaid and eight that did not. She said the increase in Medicaid expansion states was lower than in non-expansion states. Musumeci also wrote that in 18 states that expanded Medicaid there was either no waiting list or a decrease.
Those figures were cited to argue there is no correlation between Medicaid expansion and waiting lists. Jacobs said the Kaiser research ignores many factors.
“They just plotted state waiting lists against expansion decisions,” Jacobs said. “I said, ‘Well, did you control for income?’ Because most of the states that haven’t expanded are poorer states, and so richer states are better able to expand Medicaid and reduce their waiting lists. Did you control for the age of the population? Did you control for health care costs, nursing home costs?”
The failure to account for those variables, he said, means the Kaiser study is “sloppy and shoddy research.”
“I could quibble with their methodology if they actually had a methodology,” Jacobs said. “They didn’t have a methodology to control for any of these variables.”
The Kaiser report subtly reinforced Jacobs’ point about rich states. Of the Medicaid-expansion states that have no waiting list, the report acknowledges that seven had no waiting list before Medicaid expansion.
The Kaiser Foundation did not respond to a request for comment.
Jacobs said the effect of Medicaid expansion, whether intended by its boosters or not, is to put “able-bodied adults ahead of individuals with disabilities in the line.” This is because the Affordable Care Act included perverse financial incentives that tacitly encourage expansion states to cut services to the needy before cutting services to the able-bodied.
Under the ACA, states get a 90-10 federal-state matching rate to cover able-bodied adults, but as little as a 50-50 match to cover health care for those with severe disabilities. During times of budget downturns, Jacobs said, this means lawmakers are more likely to cut services to the truly needy rather than the able-bodied because it will “cost” the state more to cut funding for the latter.
“Let’s rely on common sense: Is 90 larger than 50 or larger than 75?” Jacobs said. “Last I checked it is.”
He says that’s especially problematic for the estimated 770,000 people with disabilities nationwide who are on waiting lists for community-based services allowed under Medicaid waivers. In Oklahoma, some individuals have been on the waiting list since 2006.
“Those folks still have access to health care under Medicaid. They don’t necessarily have access to personal care for their personal needs. So they either face the choice of having to wait and wait and wait, or going into a nursing home,” Jacobs said, “which is an awful, awful choice.”