Fifty years ago this week Medicaid and Medicare were signed into law. These two programs provide children, seniors, people living with disabilities and working families with access to the health care they need. To celebrate 50 years of these two programs, each day this week one of our partners will share a story about their work to ensure more people can access Medicaid. We’ll also be reflecting on the two programs and what’s ahead. 

After the murder of nine African-Americans in a Charleston, South Carolina, church last month, Rev. William Barber, the President of the North Carolina NAACP and leader of the “Moral Mondays” movement, said, the best way to honor the legacy of Reverend Clementa Pinckney and the other victims, was to overturn voting rights restrictions and expand Medicaid eligibility. As we approach the 50th anniversary of Medicaid, Barber’s comments are of particular importance. Health care in North Carolina, and the country more generally, continues to be seen as a privilege not a right. But without health coverage, North Carolinians are more likely to see their health compromised, impacting both their quality of life and their mortality. Health care access, like low wages, is a measure of the inequality that is rending the fabric of our communities.

Rev. Barber draws attention to Medicaid because North Carolina is one of 21 states—11 in the Southern region of the U.S.-- that have refused federal funds allocated by the Affordable Care Act to provide health coverage to all adults living in households with incomes below 138 percent of the poverty level. Currently, Medicaid coverage in the state is restricted to extremely poor parents (household income below 40 percent of the federal poverty level or $667/mo. for a three-person family), pregnant women, and children. Nonelderly, nondisabled adults without dependent children are ineligible regardless of income.  About 500,000 North Carolinians could benefit from expanded Medicaid coverage, according to the North Carolina Justice Center. Of these, 300,000 have no other coverage option.

A recent paper from the Paraprofessional Healthcare Institute (PHI), “Too Sick to Care: Direct-Care Workers, Medicaid Expansion, and the Coverage Gap,” indicates that of North Carolinians who are affected by the Medicaid coverage gap nearly 10 percent are direct-care workers—the home health aides, personal care aides, and nursing assistants who provide support to the state’s elders and people living with disabilities. About 45,000 direct-care workers live in households with incomes below 138 percent of the poverty level. Moreover, 29,000 of these workers live in households with incomes below 100 percent of FPL. These workers fall in the “coverage gap”: they have no new options for health coverage under the Affordable Care Act, because they are ineligible for federal tax credits that make buying insurance on the state marketplace more affordable.

Direct-care workers provide 80 percent of the paid hands-on care for elders and people living with disabilities. As the recent profile in the Raleigh News and Observer documented, this is strenuous, emotionally difficult work that is essential to the dignity and health of North Carolinians who need assistance with personal care and other tasks that many of us take for granted. It seems particularly ironic that these care providers are forced to go without care themselves

Medicaid coverage is especially important to North Carolina’s direct-care workers because fewer than one in two has access to an employer-sponsored health plan. In some cases, employers—whose primary revenue often comes from providing Medicaid funded long-term services and supports—don’t have the resources to offer affordable coverage; in other cases, erratic and part-time hours, which are typical for home care aides in particular, make workers ineligible for coverage. 

North Carolina, like much of the country, has an aging population. An additional 22,000 direct-care workers are needed by 2022 to meet the state’s eldercare needs. But finding and keeping workers is becoming increasingly difficult. It’s not surprising: wages are low, injury rates are high, and employer-sponsored health coverage is uncommon. The result is that one in two workers leave the field annually. Anyone who needs care or manages care for a family member knows viscerally what this means: a parade of ever-changing aides who lack experience and who don’t stay long enough to build the quality relationships upon which good care is built. It is tough on the family, and even tougher on those who depend on the care provided.

Closing the coverage gap in North Carolina is an opportunity to address multiple issues, from the economic and racial inequality Reverend Barber seeks to address to providing quality long-term care services. The latter has been on the agenda of North Carolina aging services for nearly a decade. The NC NOVA program awards long-term care providers for investing in training, mentoring, and other workplace innovations that improve the quality of direct-care jobs and, as a result, the quality of care. The state should take the next step and ensure that all direct-care workers have access to affordable health coverage---a healthier, more stable workforce is absolutely essential to meeting the needs of North Carolina’s elders and people living with disabilities.

Jodi Sturgeon, President, PHI
Thomas R. Konrad, Ph.D. 

Jodi Sturgeon is the president of PHI, a national nonprofit that fosters dignity, respect, and independence– for all who receive long-term care, and all who provide it. PHI is the nation’s leading authority on the direct-care workforce. This week, PHI released “Too Sick to Care: Direct-Care Workers, Medicaid Expansion, and the Coverage Gap,” which examines how the direct-care workforce is affected by state decisions not to expand Medicaid eligibility.

Thomas R. Konrad holds a Ph.D. in sociology and recently retired from the University of North Carolina at Chapel Hill, where he conducted healthcare workforce and workplace research for over 40 years, while at the Cecil G. Sheps Center and the North Carolina Institute on Aging. Dr. Konrad developed and evaluated training programs for direct care workers in various long term care settings and has conducted numerous studies of the impact of health care workforce development and workplace redesign on care outcomes with support from federal, state and foundation sources. 

Lyndon B. Johnson signing the Medicare bill. Fifty years ago today, President Lyndon B. Johnson signed into law the landmark amendments to the Social Security Act that created the Medicare and Medicaid programs. In his comments at the signing, President Johnson made explicit the connection between the right to health care, and the financial security of older Americans and families of all ages. In the half century since, these two life-changing programs have indeed provided that security to tens of millions of adults over age 65, people with disabilities, children and families, pregnant women, and low-income Americans.

At the time of enactment, roughly half of all older adults in the United States had no health insurance. Today, Medicare and Medicaid cover nearly 1 out of every 3 Americans – more than 100 million people. But there are still millions more without coverage of any kind, or with coverage, but inadequate access to care and services they vitally need.

While a pause for celebration is in order today, complacency is not.

The United States continues to spend almost twice as much per capita on health care as any other western democracy, with far less “bang for our buck,” in terms of health status and outcomes to show for it. Significant health disparities and unequal access to quality care continue to be hallmarks of our health system. These issues pose a threat to the sustainability of Medicare and Medicaid, as well as new programs established under the Affordable Care Act.

The ACA was carefully crafted to build upon – and improve – the solid footings Medicaid and Medicare provide for the health care of vulnerable populations, even as it created a new pathway to coverage for millions more through the insurance Marketplaces.

Beyond establishing the Marketplaces, the ACA has many other provisions that are already changing the health care landscape in dramatic ways:

  • First and foremost, the provision insuring more people through Medcaid was envisioned to take effect in every state, to dovetail with the eligibility guidelines of the Marketplaces. Advocates are working tirelessly in those states which have yet to close the coverage gap to make that promise a reality in all 50 states.
  • The Medicare-Medicaid Coordination Office, created under the ACA, is overseeing financial alignment demonstration projects in a dozen states to address the very real difficulties that people eligible for both Medicare and Medicaid confront daily due to the different rules and benefit guidelines, and often fragmented and uncoordinated care they produce. Our Voices for Better Health Project is working with state partners and geriatric provider experts to help implement these demonstrations to provide the best integration and coordination of care possible, while protecting consumers and helping them make their voices heard in the process.
  • The Center for Medicare and Medicaid Innovation (“The Innovation Center”) is another creation of the ACA. This center is working to seek out, evaluate and pilot new payment and service delivery models that aim to achieve better care for patients, better health for communities, and lower costs through improvement of the health care system.

There is much more advocacy needed to expand the reach, quality, equity and cost effectiveness of both Medicare and Medicaid in the decades ahead. Community Catalyst and our state partners are committed to working together to transform our health care system into one that operates effectively and efficiently to ensure all people get the care they need and that invests in keeping them healthy. 


For today, please join us in wishing a Happy 50th Anniversary to Medicare and Medicaid!

Fifty years ago this week Medicaid and Medicare were signed into law. These two programs provide children, seniors, people living with disabilities and working families with access to the health care they need. To celebrate 50 years of these two programs, each day this week one of our partners will share a story about their work to ensure more people can access Medicaid. We’ll also be reflecting on the two programs and what’s ahead. 

Hannah is a 27-year-old member of the Confederated Salish and Kootenai Tribes in northwest Montana. She works as a massage therapist and research assistant, and is also a caregiver for her elderly grandmother and quadriplegic cousin. Two years ago, Hannah was diagnosed with Lyme disease and recently her health has declined drastically.

Right now, Hannah is uninsured. She can’t afford health insurance and doesn’t make enough to qualify for tax credits. She’s able to access basic health care through Indian Health Services (IHS), but is unable to get the specialist care she needs to manage her Lyme disease. She had to pay $900 out of pocket for lab work just to get a definitive diagnosis.

“Having expenses for medical care is really hard for my family,” Hannah said. “Medicaid would give me the chance to see a doctor where I live and  live a healthy, normal life.”

Hannah is just one of approximately 20,000 American Indians in Montana who will benefit from closing the coverage gap by expanding access to Medicaid. Montana ranks highest of any state in uninsured American Indians (40 percent) and the second lowest in number of American Indians with private insurance (28 percent). IHS faces an ongoing and severe funding shortage, with federal funding covering only 60 percent of the demand for care. Many American Indians who rely on IHS for care experience a lack of access to specialty care, like Hannah, preventative care, or early treatment for chronic disease. Medicaid plays a very important role in bridging the gap in access to care.

Current Medicaid recipients in Indian Country are able to seek care from IHS-run tribal or urban Indian clinics, as well as other non-tribal health care facilities. In addition to better health outcomes and continuity of care, Medicaid provides an influx of federal dollars that creates an economic boost to IHS and communities in Indian Country. This federal funding can increase the capacity of IHS to meet the health care needs of the community, improve their core services, and update equipment and facilities.

Services provided by IHS to American Indian Medicaid recipients are 100 percent reimbursable by the federal government, and this reimbursement rate will not change when the coverage gap closes. Not only do Medicaid recipients get better access to health care, and not only does IHS receive a much needed influx of funds, but there is no fiscal obligation to the state.

For years, Medicaid has helped to create strong and healthy individuals, families, and communities in Indian Country. As we celebrate Medicaid’s 50th anniversary, we should celebrate the positive impact Medicaid has on reservations and in urban Indian communities, and we should also remember that we have a unique opportunity to continue to improve health care and support communities in Indian Country through Medicaid expansion. For Indian Country, closing the coverage gap is one step toward eradicating generations of extreme health disparities affecting American Indians. Most of all, it is a commitment that will strengthen Montana’s families, communities, and economy.

Sarah Howell, Executive Director, Montana Women Vote

Fifty years ago this week Medicaid and Medicare were signed into law. These two programs provide children, seniors, people living with disabilities and working families with access to the health care they need. To celebrate 50 years of these two programs, each day this week one of our partners will share a story about their work to ensure more people can access Medicaid. We’ll also be reflecting on the two programs and what’s ahead. 

At Voices for Virginia’s Children, we are reflecting on Medicaid’s 50th anniversary and what the program has meant to generations of children and families here in Virginia. 

If children don’t have adequate access to health care – both preventive care and treatment – few of our other goals for them are attainable:

  • Lack of routine well-child visits in young children can mean missing the diagnosis and treatment of developmental delays, which can cause kids to struggle in school.
  • Kids without health care coverage don’t get taken to the doctor when they’re sick; instead, illness can escalate until costly and crisis-oriented emergency care is required.
  • Without health insurance for their kids, parents also miss the age-appropriate guidance from pediatricians or family physicians about developmental milestones to help them provide optimal care for their children.

Nationally, more than 71 million children now access health care because they have coverage through either Medicaid or the Children’s Health Insurance Program (CHIP). In Virginia (you can check your state here), almost one million kids have this coverage, either through Medicaid, for families who earn a little above the poverty line (143 percent of the federal poverty level) and FAMIS (our CHIP program) for families who earn up to twice the federal poverty level. (The federal poverty rate in 2015 is a meager $24,250 for a family of four. 

Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefits for children are “a model for pediatric care.” EPSDT provides comprehensive coverage, including dental, vision and hearing screenings and treatment – recognizing that kids whose teeth hurt or who cannot see or hear the teacher are not going to be able to learn. In fact, research shows that increased enrollment in Medicaid and CHIP not only have a positive effect on child health indicators such as obesity and teen pregnancy, they also have a positive effect on academic achievement.

We celebrate the success of Medicaid because kids are still struggling in poverty at disproportionate rates in this country. In Virginia, almost 300,000 children live below the poverty line—what’s worse, we are one of only 10 states in which the child poverty rate got worse between 2012 and 2013. Kids growing up in poverty are already starting out behind their peers in more economically secure families. Yet for all the ways these kids may have the deck stacked against them from the start, health care doesn’t have to be one of them—and for that we can credit Medicaid.

Just as kids in poverty struggle to succeed in life if they don’t have regular access to health care, their parents do, too. Research shows us that when parents don’t have health insurance, the whole family is at risk.

  • Uninsured parents with chronic illnesses often have to go without needed treatments, making them less able to provide consistent care for their kids.
  • In low-income families, one medical emergency for a parent without insurance can mean financial ruin—making it impossible to meet their kids’ basic needs.
  • Untreated maternal depression can have dire, lifelong consequences on the wellbeing of young children.

Many states have figured out that allowing low-income, uninsured adults – including the 25 percent who are parents of children younger than 18 – to enroll in Medicaid according to the provisions of the Affordable Care Act is a smart investment in our future. Not only will we have a healthier workforce now, we will improve the health and academic trajectory of tomorrow’s workforce. Kids whose parents are insured are more likely to have insurance themselves and be taken to the doctor for routine care.

Unfortunately in Virginia, Medicaid coverage is very restricted for adults in poverty, including parents. Depending on where in the Commonwealth you live, making as little as $7,980 a year could mean you earn too much as a parent in a family of four to qualify for Medicaid.

The great news is that we have an opportunity to improve the situation for low-income families, helping both parents and kids by closing the coverage gap between existing adult Medicaid eligibility levels and eligibility for tax credits in the Marketplace. As child advocates, we are still working with many others to find a Virginia-specific solution to the dilemma of uninsured, low-income adults.

So while we celebrate the generations of kids who have grown up with access to comprehensive health care because of Medicaid, we must also seize the opportunity to improve outcomes for kids and parents in the future through increased Medicaid coverage. 

--Margaret Nimmo Crowe, Executive Director, Voices for Virginia’s Children

The end of Congressional détente?

Things have been relatively quiet in Congress lately and there has even been some bipartisan work getting done, but that could change relatively soon and I am not even talking about the continued parade of ACA repeal votes that are coming down the pike in the Highway bill or via budget reconciliation. Those efforts are getting shrugged off and consigned to the realm of symbolism.  I’m talking about a series of must-do measures that could bring us back to the world of hostage-taking, and government shut-down brinksmanship. Here are three leading flashpoints:

Appropriations: It is now clear that the appropriations process will not be completed on time. That means Congress will have to pass a continuing resolution (CR) in order to avoid a government shut-down. A CR would be easy to pass except that parts of the Republican caucus seem intent on using it to make policy changes, notably to strip all federal funding from Planned Parenthood.

Social Security disability insurance: The SSA Trustees report shows that unless Congress acts, millions of people with disabilities will receive a 19 percent cut in their already meager benefits. Again, an easy fix is available for Congress—they can vote to transfer funding to the SSDI account from the larger retirement trust fund (as Congress has done several times in the past with little fanfare).  However, congressional Republicans are seeking changes in the program as the price for extending its life, setting up what is sure to be a tense negotiation.

Debt limit: Although the timing is uncertain, analysts expect the Treasury Department’s measures for making payments on government debt will be exhausted before the end of the year. As always, Congress can simply vote to raise the debt ceiling to honor the obligations that they themselves have voted to incur. Beyond that, the debt ceiling could be scrapped altogether, an approach recommended in a recent GAO report. That would remove the recurrent threat of US government default, a threat which the GAO found harms the economy. Will Congress act rationally or will we be treated to another game of chicken regarding the nation’s economic health?

The dilemma for Republican Congressional leaders in all of these cases is that a significant part of their base both in and out of Congress wants to use these must-pass bills as “hostage-taking” opportunities to extract policy changes. However, both the policy changes themselves and the repeated threats of shut-down and default tend to be unpopular with the larger voting public.

The health care tie-in?  In some of cases—e.g. limiting access to family planning services by defunding PPFA—the connection is very direct. In other cases, the impact comes more from the economic harm that could be done to vulnerable populations, via benefit cuts or government shutdown and also because each “hostage-taking” incident represents a threat to vital health and social-welfare programs. In either event, health care advocates will need to keep a close eye on these developments and be prepared to pressure Congress to do the right thing.

A funny thing happened on the way to budget reconciliation

Following the victory in King v. Burwell it seemed that the appetite for another symbolic attempt to repeal the ACA was waning, but now it appears to be back in full force. What happened? Senators went home and talked to their base voters. Although ACA repeal continues to lose steam with the general public, it still commands a majority within the Republican Party. Hence the fruitless repeal votes will continue.

More victories for CTG but some states still don’t get the message

Following on the votes in the Montana legislature to close the coverage gap by accepting federal funds to provide insurance to low income adults, two more states in the West seem poised to follow suit. Governor Bill Walker of Alaska announced that he would move ahead with closing the coverage gap and negotiators in Utah announced a breakthrough in their talks will also likely lead to expansion. That would make three states in the western part of the country moving forward this year. As the number of states refusing the overwhelming logic in favor of coverage declines it becomes harder and harder, given the geography and demography of states and people in the coverage gap, to ignore the continuing role of race in shaping our politics. While symbolic actions, such as removing the confederate battle flag in South Carolina are a step forward, more concrete actions to close disparities in health and economic wellbeing are necessary. There is no better place to start than closing the coverage gap.