AHCCCS population age breakout

After years of decline, the percentage of Arizonans without medical insurance has risen again.

That’s bad news for Gila County, where a quarter of the residents rely on this state’s version of Medicaid — the Arizona Health Care Cost Containment System (AHCCCS). The Affordable Care Act expanded AHCCCS and also offered insurance for working families, which reduced the share of Gila County residents reliant on AHCCCS from 29 percent to 25 percent — or 13,000 of the county’s 53,000 people.

The number of people covered by AHCCCS in Gila County has risen 2 percent in the past year — a gain of about 300 people — and in line with the statewide average.

This year the number of people without health insurance in Arizona rose by 12,000 — but still stood at just 12 percent — compared to 21 percent in 2013, before the Affordable Care Act took effect. Roughly 750,000 Arizona residents still have no health coverage.

The open enrollment period to sign up for a plan ends on Dec. 15. To look for a plan, go to healthcare.gov.

Most people who enroll can still get a subsidy that covers some or all of their premium, depending on family income. Most counties have multiple plans to choose from.

People with incomes less than 400 percent of the poverty line — or $85,000 for a family of three — can qualify for a subsidy. Some 84 percent of those signed up for coverage this year got a subsidy.

People can also qualify for AHCCCS coverage with a family income of up to 138 percent of the federal poverty level — which often involves no out-of-pocket costs. In some cases, children can get AHCCCS coverage even if their parents don’t qualify.

However, more bad news may await — if a lawsuit by states supported by the U.S. Department of Justice finally kills the Affordable Care Act (ACA). The Trump administration has called repeatedly for the repeal of the ACA and in a rare move declined to defend the federal law from legal challenge.

A federal appeals court has already heard arguments in the lawsuit that claims the way Congress enacted the Affordable Care Act violated the Constitution. If the lawsuit succeeds, some 600,000 Arizonans could lose their health care. That includes both people who have obtained insurance through the ACA exchanges and people who gained coverage through the federally funded expansion of AHCCCS.

Arizona ranks 41st nationally in the share of the population without health insurance. About 8 percent of children and 11 percent of adults lack insurance. That’s still an overall decline of 6 percent in the ranks of the uninsured in Arizona since 2010.

The Arizona Legislature narrowly voted to accept federal funding to expand eligibility for AHCCCS to 138 percent of the federal poverty level. That’s about $45,000 annually for a family of six or $16,000 for a single person.

The uninsured rate has risen as Congress has chipped away at the provisions of the ACA. Congress has eliminated a penalty for not having insurance, which previously provided money for subsidies and give people an incentive to buy insurance.

The state Legislature has also imposed a work requirement and a five-year, lifetime limit on receiving benefits — which could further reduce coverage by AHCCCS.

This year, Congress allowed the sale of “short term” plans that don’t meet the full requirements of regular ACA coverage — effectively providing only “catastrophic” coverage in many cases.

Companies have begun to market the cut-rate plans to healthy people, which could leave only people with medical issues on the full-coverage plans, driving up rates.

National studies show that the expansion of Medicaid programs like AHCCCS has saved lives. One study concluded that gaining Medicaid coverage for 55- to 64-year-olds reduced deaths over a 16-month period by about 2 percent — which amounted to a 70 percent decline in the expected death rate.

Extrapolating, research said the states that didn’t expand their Medicaid programs likely suffered an extra 16,000 deaths. Arizona expanded AHCCCS, but state law will revoke the expansion if federal funding for the added population falls below 95 percent.

Having medical insurance also dramatically reduces financial stress, since medical bills remain the number one reason for bankruptcies.

The lack of medical care hits rural areas hardest. Studies suggest one-third of people who have insurance in rural areas put off or skip medical care because they can’t find a doctor and don’t have the time or money to travel to find one.

Statewide, 28 percent of residents rely on AHCCCS. The program has grown steadily since its launch in 1985. The number covered has grown from 600,000 in 2000 to 1.9 million in 2016.

The federal government provides 75 percent of the funding, the state’s general fund about 16 percent and the counties about 3 percent.

Children account for 44 percent of those covered, adults under 64 for about 50 percent. Adults older than 64 make up about 6 percent, mostly the impoverished disabled cared for in nursing homes. Nonetheless, the Arizona Long Term Care System (ALTCS) coverage of nursing home bills for the impoverished elderly accounts for one-quarter of AHCCCS spending. The county share of ALTCS has risen sharply.

The state’s AHCCCS program relies on a managed care model and has long been lauded as one of the most cost-effective Medicaid programs in the country. The program’s enrollment has soared since 2012, but the federal government has borne almost the total cost of the increase. State general fund money going into the program has remained steady at about $1.2 billion since 2013.

The program faces an uncertain future. The lawsuit seeking to overturn the Affordable Care Act poses the most immediate threat, with a federal appeals court decision due at virtually any moment.

The ACA remains broadly popular, with support of 77 percent of voters in some recent polls. The overwhelming majority of voters also support key provisions of the ACA, including allowing children to remain on their parent’s health plan until the age of 26 and barring insurance companies from extending coverage to people with pre-existing conditions. This helped blunt efforts to “repeal and replace” the ACA in Congress, but the court case could overturn the act by the back door, threatening coverage for about 10 percent of Arizona’s population. However, those provisions would also fall should the lawsuit succeed. Arizona is one of the 19 Republican-led states in the lawsuit seeking to repeal the Affordable Care Act.

The foes of the ACA argued before the 5th Circuit Court of Appeals in Texas v. Azar that when Congress in 2017 eliminated the penalty for not having insurance, it effectively rendered the whole ACA unconstitutional. The U.S. Supreme Court in 2012 had held that the penalty for not having insurance was key to its constitutionality.

A lower court in Texas has already ruled against the ACA. If the appeals court agrees, the case would almost surely go to the U.S. Supreme Court next year — which would be the third time the court has been asked to rule on the constitutionality of the act.

Even if the expansion of Medicaid survives that legal challenge, health care experts predicted a continued rise in the number of uninsured as the various modifications of the AHCCCS take effect.

For starters, the administration has imposed a new rule barring eventual citizenship for any legal immigrant who receives benefits. Current law allows a legal immigrant to qualify for AHCCCS after five years in the country.

In addition, the administration has proposed saving money by turning the whole Medicaid program into a block grant run by the states. The block grant approach would probably hurt states like Arizona that already have a relatively low-cost, highly efficient program.

Moreover, experts say the work requirement will likely reduce the number of people who can receive benefits. The new rules will require anyone on AHCCCS to either report they’re actively looking for work or performing specified community service. Experts say few people on AHCCCS can work — they’re either single mothers with children who would pay more in child care than a job would produce or they are medically disabled or too sick to work.

In Arkansas, one in four Medicaid beneficiaries subject to work requirements lost coverage in the first seven months of the program — mostly because of difficulties in filling out the paperwork and providing the required documentation. Despite the loss of coverage by 18,000 people, the program had no impact on the underlying employment rate. Studies suggest that about 60 percent of the people receiving AHCCCS already work and most of those who don’t aren’t able to work.

The new Arizona rules will exempt from the work requirement pregnant women up to the 60th day after they give birth, former foster children up to the age of 26, tribal members, people with a serious mental illness, people with a federally recognized disability, people who are medically frail, survivors of domestic violence, the homeless, the designated caretaker of a child under 18, people on unemployment, people in treatment for substance abuse and full-time students.

AHCCCS estimates only 120,000 people on the program now will end up having to comply with the new requirements, which includes at least 80 hours a week of “community engagement activities.” That would include a job, training, job search activities, community service and education.

Nonetheless, the need for a slew of new documents could cost perhaps 30,000 of those people their health care, according to national studies.

Contact the writer at paleshire@payson.com

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