West Virginia and the ACA’s Medicaid expansion

Enrollment up 53%, but West Virginia officials are considering a work requirement for expansion population

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West Virginia’s leaders opted to expand Medicaid under the Affordable Care Act (ACA) starting on January 1, 2014.  They are using mostly federal funds to provide Medicaid for the newly-eligible population of low-income adults, most of whom have jobs but no option for employer-sponsored health insurance. Starting in 2017, the state began to pay 5 percent of the cost, and that will climb to 10 percent by 2020.

Under the new eligibility guidelines, West Virginia’s Medicaid/CHIP enrollment grew by almost 62 percent from mid-2013 and October 2016. But by August 2018, net enrollment growth stood at 53 percent, so enrollment declined in 2017-2018, after increasing sharply in the first few years of Medicaid expansion.

Total enrollment growth includes people who were already eligible (but not yet enrolled) prior to 2014, but even if we only consider the Medicaid expansion population, enrollment had grown by 164,400 people as of the end of June 2015, and by 178,394 as of August 2016. That’s significantly more than the 93,000 people that West Virginia had projected to enroll by 2020 under the expanded eligibility guidelines, but enrollment appears to have stabilized, as the total number of people enrolled under expanded Medicaid declined slightly by January 2017, to 174,026, and declined further, to 165,917, by March 2018. By December 2018, it had declined to under 154,000 people. Still far above the state’s original projections, but well below the 2016 high.

But despite the unexpectedly large enrollment in Medicaid expansion — combined with the fact that the state began paying a portion of the Medicaid expansion costs starting in 2017 — West Virginia does not appear to be heading for a Medicaid budget crisis. That’s because per-person costs have been coming in lower than expected, thanks in part to numerous reforms that the state has put in place.

West Virginia is considering a Medicaid work requirement for the expansion population

As of late 2017, West Virginia’s Department of Health and Human Resources was considering the possibility of seeking a waiver from the federal government in order to implement a work requirement for the state’s Medicaid expansion population (as of December 2018, West Virginia had not passed legislation calling for a work requirement, and the state did not have any pending 1115 waivers with CMS, so nothing had been submitted at that point).

Work requirements were a non-starter with the Obama Administration, but the Trump Administration has made it clear that they are open to the possibility, and work requirements have already been approved for Kentucky, Indiana, New Hampshire, Wisconsin, and Arkansas; the work requirement in Arkansas took effect in 2018, and 12,000 people lost their coverage in the first few months for failure to comply with the reporting requirements. The approved work requirements in the other states take effect in 2019.

Consumer advocates in West Virginia have criticized the possibility of a work requirement, noting that such programs tend to just make it harder for people to maintain their health coverage, due to documentation requirements, despite the fact that the majority of Medicaid expansion enrollees are already in a household where at least one person is working.

The state has already entered into a $300 million contract with Optum to verify eligibility for various need-based programs, including SNAP and Medicaid. If a work requirement were to be added to Medicaid, it would increase the reporting and verification measures necessary in order to confirm ongoing eligibility for Medicaid.

Medicaid expansion helping to combat opioid crisis

The opioid crisis has hit West Virginia particularly hard, and the state has the nation’s highest drug overdose death rate. But 22,000 people covered under expanded Medicaid have received treatment for mental health and substance abuse disorders. Without Medicaid expansion, most of those people would have been uninsured and unable to access treatment.

New governor supports continued Medicaid expansion

West Virginia Governor Jim Justice took office in January 2017. He campaigned and was elected as a Democrat, but in the summer of 2017, during his first year in office, he switched to the Republican party. However, Justice had reiterated his support for Medicaid expansion in the weeks leading up to his party switch, stating in late June 2017 that it would be “beyond catastrophic” if the people who had gained coverage under Medicaid expansion were to lose it.

Former Governor Earl Ray Tomblin, who was instrumental in West Virginia’s acceptance of Medicaid expansion, was term-limited and did not seek re-election. Justice was vying with Republican Bill Cole for the governor’s office, along with candidates from the Libertarian and Mountain Parties.

Although Medicaid expansion was a topic of contention in many of the races around the country in 2016, both Cole and Justice said that they would leave Medicaid expansion intact in West Virginia, and would work to find ways to pay the state’s portion of the costs that kick in starting in 2017.

Substantial impact on uninsured rate

West Virginia had the sixth highest drop in uninsured rate during the first half of 2014, due primarily to Medicaid expansion (as of July 2014, 132,556 people in WV had enrolled in Medicaid, while 25,856 had enrolled in subsidized private coverage through the exchange).

According to US Census data, the state’s uninsured rate was 14 percent in 2013, and had fallen to 5.3 percent by 2016. West Virginia’s uninsured rate had been similar to the US average (14.5 percent) in 2013, but the state’s uninsured rate in 2016 was well below that national average at that point, which was 8.6 percent.

Expansion of Medicaid has played a primary role in West Virginia’s sharp reduction in the uninsured rate.

Who is eligible?

As of 2014, West Virginia Medicaid is available for these legally-present residents, in addition to the aged, blind, and disabled.

  • Adults with incomes up to 138 percent of poverty
  • Children with household incomes up to 300 percent of poverty are eligible CHIP (Children’s Health Insurance Program)
  • Pregnant women with incomes up to 158 percent of poverty.

This booklet from the West Virginia Bureau for Medical Services shows eligibility levels based on total income.

How do I apply?

You can apply for West Virginia Medicaid through the federally-run exchange by visiting HealthCare.gov or calling 1-800-318-2596 24 hours a day.

Or you can apply through the state at www.wvinroads.org and that site can also provide SNAP and cash assistance programs for eligible residents.

Medicaid enrollment is year-round – there is no specific time frame during which applications must be completed.

How many people have enrolled?

As of mid-July 2014, there were 132,556 new Medicaid enrollees who were all newly-eligible under the expanded guidelines. Although most of the newly-eligible population enrolled during the first year, the number of newly-eligible enrollees had grown to 164,400 by June 2015, and to 178,394 by August 2016. But enrollment in expanded Medicaid declined slightly by the beginning of 2017, to 174,026, and declined further, to 153,874 by December 2018. (every state has had additional enrollees who were already eligible but not previously enrolled – they are not included in these counts, even if they’re now enrolled in Medicaid).

In 2013, the Kaiser Family Foundation estimated that about 143,000 people in West Virginia would be newly-eligible for Medicaid as of 2014. But the state’s estimate had been much lower, with a projected expansion enrollment of 93,000 by 2020. Ultimately, even Kaiser Family Foundation’s projection was low, as nearly 166,000 people were enrolled in expanded Medicaid in West Virginia as of 2018.

Opponents of Medicaid expansion predicted that states with a surge in Medicaid enrollment would find that Medicaid patients were unable to get appointments for primary care, but West Virginia doctors weren’t indicating that was a problem. Instead, some of their challenges include a significant population of newly-insured people who are requesting pain medication at office visits, and patients who have previously been on free drug samples and need to be switched to another drug that’s covered by Medicaid.

There have been – and will continue to be – some growing pains, but it appears that the state’s providers are handling the influx of new patients well.

Uncompensated care costs decline sharply

According to data compiled by West Virginians for Affordable Health Care, hospitals in West Virginia saw a 40 percent decline in uncompensated care costs from 2013 to 2014, thanks in large part to Medicaid expansion that has resulted in far fewer uninsured residents in the state.

But although the hospitals acknowledge that their uncompensated care and charity care costs have declined significantly, some also note that Medicaid reimbursements are less than the cost of providing care, and that their losses on Medicaid volume are offsetting the improvements they’ve seen in uncompensated care.

The decision to expand Medicaid

West Virginia had initially considered setting up a state-run exchange, but later opted for a partnership exchange, citing cost as one of the reasons for avoiding a fully state-run exchange.

State leaders have said that given the choice between a state-run exchange and Medicaid expansion, the latter seemed like it would provide more bang for the buck (and judging by the state’s extremely successful Medicaid enrollment in 2014, it would appear they were correct).

In May 2013, Governor Earl Ray Tomblin announced that West Virginia would proceed with Medicaid expansion. Enrollment for newly-eligible residents began on October 1, 2013, with coverage effective January 1, 2014.

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.

How to apply in WV

Apply through HealthCare.gov or by calling 1-800-318-2596 (24 hours a day).

Eligibility: The aged, blind, and disabled.  Also, adults with incomes up to 138% of FPL; children with household incomes up to 300% of FPL are eligible CHIP; pregnant women with incomes up to 158% of FPL.

West Virginia section