A look at Pennsylvania’s new Medicaid option, one week in

    Will Bethea of Pennsylvania Health Access Network counsels a prospective enrollee during a sign-up session at the Coleman Library in Northwest Philadelphia. His group has helped nearly 400 people enroll in Medicaid since eligibility expanded in the state. (Emma Lee/WHYY)

    Will Bethea of Pennsylvania Health Access Network counsels a prospective enrollee during a sign-up session at the Coleman Library in Northwest Philadelphia. His group has helped nearly 400 people enroll in Medicaid since eligibility expanded in the state. (Emma Lee/WHYY)

    State officials estimate that as of January 1, 2015 about 600,000 Pennsylvanians became eligible for Medicaid through its newly expanded Healthy Pennsylvania option.

    Enrollment began last month, and as of Monday, a spokesperson reported the state had received at least 114,000 household applications (it’s unclear how many came from people who were previously uninsured).

    One of those applications came from 45-year-old Marsheen Ellis Hartfield.

    Low income adults benefit

    Hartfield has been a home health worker in Philadelphia for nearly a decade. She helps people with basic tasks, like bathing, dressing and eating.

    “We have to stay healthy ourselves, and if we’re not healthy then, you know, they can’t stay healthy because we can’t take care of them.”

    Hartfield earns about $9 an hour and is the primary breadwinner for her family of three.

    Before this new medicaid option, she fell into a coverage gap. She made too much to qualify for medicaid, but she also didn’t make enough to qualify for help buying private insurance through the Affordable Care Act’s online marketplace (surprised to learn this last year, she met with two marketplace counselors, to double check).

    To be eligible for those federal subsidies, a family would have had to be at 100 percent of the federal poverty level or above.

    As a result, Hartfield and her husband remained uninsured and postponed some checkups this past year because of the out-of-pocket copays (her son, 13 years old, does qualify for state coverage).

    At one point, Hartfield says her husband went to the emergency room in a lot of pain, but left with more than $1,000 in medical bills.

    “He was supposed to get a procedure done, but being as he didn’t have health insurance, he was like, ‘Forget it! Because I can’t pay out of pocket.'”

    Sitting at her dining room table, Hartfield pulled out a letter underneath a stack of those ER bills. It was dated December 2014 and confirms that she and her husband will be enrolled in Medicaid this month, thanks to those eligibility changes that took effect this year.

    “I’m going tell him, ‘look, now you got it [Medicaid], now that stuff you’ve been crying about, now you can get it done!’ You know, because he needs it,” she said.

    Pennsylvania joins its neighbors

    Starting last January, states began tapping into federal funding to expand the number of people eligible for medicaid by broadening the income guidelines to just above the poverty line.

    It means able-bodied, childless adults earning up to about $16,000 a year are eligible, as are more families. A family of four with an annual income of up to about $30,000, for example, now qualifies for Medicaid.

    “Pennsylvania was really the last state in its region to move ahead to expanding coverage to those in the coverage gap,” said Joan Alker, a Medicaid expert and director of Georgetown University’s Center for Children and Families.

    Alker is referring to neighboring Delaware, Ohio, Maryland and New Jersey that have already expanded Medicaid in some form.

    Overall, 28 states and Washington D.C. have expanded Medicaid.

    Not a traditional expansion

    Pennsylvania Governor Tom Corbett, a Republican, waited until 2015 to expand Medicaid, so he could get federal permission to make some changes.

    “We need a medical insurance program that’s designed for Pennsylvania,” Corbett said last year, when he submitted the proposal. “One size does not fit all.”

    Federal officials didn’t give the go ahead on everything, like a controversial job training requirement. But benefit changes have gone through for some enrollees and others with certain incomes will start paying premiums in 2016.

    “There’s a lot of complicated nuances to the governor’s plan,” said Alker, pointing to consumer protection mechanisms that will now involve the state’s department of insurance.

    “Healthy Pennsylvania,” as the Medicaid option is called, also emphasizes the use of private insurance for those who are newly eligible.

    It means that Hartfield and others must select an approved Medicaid-funded plan offered by one of several insurers in the region.

    Alker says this is actually not much different from how Medicaid in Pennsylvania already operates.

    “Medicaid already uses [those] private insurers to deliver services through managed care,” she said. “So potentially what would have been different really is coming next year in 2016.”

    One part of Corbett’s proposed changes for current enrollees is still awaiting final approval.

    The future of Medicaid in Pennsylvania and beyond

    Pennsylvania was one of four states to receive a federal waiver to make changes to a traditional expansion.

    Pennsylvania’s incoming governor, Tom Wolf, a Democrat, has said he plans to scrap Corbett’s changes and move forward with a traditional expansion.

    Alker says that would be an easy request from federal officials.

    He would still need some legislative approval at the state level during the budget process.

    Regardless, Alker says Corbett’s original proposal – with its focus on job training, charging premiums, and trying to establish healthy behavior requirements – is sure to influence other states who may be considering an alternative proposal in the coming year.

    In fact, she expects any state moving forward with an expansion will attempt the waiver approach.

    “Those are themes I expect we’ll see continue to be discussed,” said Alker. “And certainly the governor participated and contributed to those ongoing discussions that we’re seeing around the country in those emerging areas.”

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