Medicaid and What You Should Know

By Contributing Writer, Amy Ferraro Whitsett

I will start with the cancer part of my story. I was diagnosed at age 45 with early-stage breast cancer. I was fortunate it was found on a mammogram before it could be felt. The worst part was the time between the second mammogram and the biopsy result. Trying to be helpful, the radiologist told me it was most likely cancer. But since breast cancer was NOWHERE on my radar, I was shocked and confused. Once diagnosed, and through the good fortune of having a well-positioned friend and a super helpful nurse practitioner as my PCP, I was seen by a team of doctors less than 72 hours later. Then I was on my way to surgery, chemotherapy, radiation, genetic testing, and anti-hormone therapy at one of the best institutions in the world. I have supplemented it with alternative medicine, lots of yoga, lots of reading, more exercise, a naturopath, and supplements. The experience sucked, but there have been silver linings.

I have spent the last 25 years working in the health and human services arena, behind the scenes. I helped agencies gain funding so that they can serve consumers. Over the years I have joked that I “kill trees to save children” or “would make a lousy social worker so I make sure the social workers have money to do what they need to do”. I love my work, but my personal experience gave me a longing to do more on the front lines and ensure that the public understands the benefit of certain programs I have been fortunate to work with, including Medicaid.

I want people to know about the positives of Medicaid and how to access it if they need to. There are two large public health insurance programs in the United States, Medicare and Medicaid.

  • Medicare is for individuals over aged 65 and certain aged, blind, and disabled.

  • Medicaid is a means-tested program for certain groups that do not have access to health insurance or whose health insurance is limited.

There are dual eligibles, eligible for both programs.

How Most Americans Get Health Insurance

Today, largely because of the Affordable Care Act (ACA), you can apply via streamlined, online systems that determine if you are eligible for Medicaid or should purchase a system via the federal or state exchange (depending on where you live). There is also a more traditional collaboration with other benefit programs such as the supplemental nutrition program (SNAP).

Approximately 20% of Americans are insured through Medicaid and Medicaid pays for nearly half of all births. Medicaid is administered by the states and territories but funded by both the federal and state governments (for the purpose of this post, state is inclusive of territories and the District of Columbia). There is a separate program, the Children’s Health Insurance Program (CHIP), that covers additional children and in some cases their parents and is closely aligned with Medicaid. States must cover certain groups, for example, children at or below 138% of the federal poverty level (FPL). States then have the option to cover other groups.

There are also required and optional services. Some of the services called optional in law are not optional in practice, for example, prescription drugs. It would not be practical nor cost-effective for Medicaid to not pay for prescription drugs. When Medicaid was created in 1965, prescription drugs were not part of private insurance either because they were not as prevalent as they are today, hence some of the out of date lingo.

The ACA sought to reduce and ideally eliminate the number of uninsured in the United States by increasing the number eligible for Medicaid (Medicaid expansion) and creating marketplaces where individuals and small companies who do not have access can purchase insurance. Individuals who do not qualify for Medicaid because they are over income may be eligible for a subsidy to help defray costs, up to 400% of the FPL. The Supreme Court ruled that the penalties imposed on states for not expanding is unconstitutional. Thus, not all states have expanded and there is still a sizable uninsured population.

“Medicare for All” is a catchphrase that theoretically means a single health insurance program. It is more politically prudent to say “Medicare” for all than “Medicaid” for all because Medicaid is often associated with welfare. What it means varies widely, from putting everyone on Medicare as we know it, to scrapping Medicare and starting over, to expanding the ACA for all.

Whatever happens, Medicaid has yielded many benefits to direct recipients and society at large. Since Medicaid was implemented, we have reduced infant mortality, improved outcomes for low-income children, provided more services for the disabled and eased the costs of healthcare on all Americans. Medicaid is the largest funder of long-term care for the elderly and the disabled. And it will be put to the test with the COVID-19 pandemic.

As for breast cancer treatment, if a man or woman already enrolled in Medicaid is diagnosed with breast cancer treatment will likely be covered. If they reside in a state that has not expanded, they may not be eligible for coverage, regardless of income, if they are not in an existing coverage group.

The ACA mandated that private insurance, individual insurance plans, and state Medicaid expansion programs cover breast cancer screenings at no cost in accordance with recommendations from the United States Preventive Services Task Force (USPSTF) and the Health Resources and Services Administration (HRSA). If an individual is covered by a traditional Medicaid coverage group, coverage of screenings will be based on the optional service coverage in the state, though most states will cover screenings (the preceding information is from The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) helps low income, un-and under-insured women access screening procedures and referral to services.

The Breast and Cervical Cancer Prevention and Treatment Act (BCCPTA) gives states the option to grant Medicaid coverage to women if they are uninsured, under 65, and diagnosed with breast or cervical cancer via an NBCCEDP screening. The eligibility criteria vary from state to state.

As I close out this post, I am sure some of you think that it is long and technical for a blog post. Medicaid is incredibly complicated and if you need to access it, it comes down to where you live. But it is woven into our healthcare fabric and has yielded great benefits.

If you want to know more, is a good place to start.

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