“During the phaseout, we should implement work requirements for healthy working-age adults in the Medicaid expansion population. Obamacare overextended Medicaid beyond those people that the program was intended to serve — the disabled elderly, pregnant women and needy children. Too often now, these people and their families have been forced onto waiting lists while money has poured into the expansion population.”
— Sen. Ted Cruz (R-Tex.) and Rep. Mark Meadows (R-N.C.), op-ed in the Wall Street Journal, March 15, 2017 

Cruz and Meadows called for a phase-out of Medicaid expansion under the Affordable Care Act, in a co-authored opinion piece, arguing that the Republican replacement bill doesn’t go far enough to change the health-care law.

They argued that the health-care law, a.k.a. Obamacare, expanded Medicaid to non-elderly adults while “the disabled elderly, pregnant women and needy children” are “forced onto waiting lists.” So we looked into it: Did Obamacare expand Medicaid at the expense of people who are on wait lists for Medicaid services?

The Facts

There’s no wait list for basic medical care for eligible Medicaid enrollees, including pregnant women and needy children. The wait lists that Cruz and Meadows are referring to are for optional services for specific populations, such as seniors and people with intellectual and developmental disabilities or chronic illnesses.

States can offer these services so that certain people can get care at home or in their own community, rather than in an institution. Services include respite care, in-home caretakers and group homes.

Thirty-five states used wait lists in 2015. States have broad discretion over Medicaid, including what optional services to cover and whether to expand coverage to get people off wait lists. Not everyone waiting may be eligible for Medicaid because some states don’t check the person’s eligibility until a slot opens.

Whether people move off the wait list depends on many factors, such as how urgent their needs are, how long they’ll need services and whether the states have money to pay for them. Many times, a slot only opens up if someone receiving services moves out of the state or dies.

Cruz’s staff pointed to a column published by right-leaning think tank Illinois Policy Institute about a state program that offers these optional services to people with developmental disabilities. From the column:

“According to the most recent data from the state, there are 18,701 Illinoisans on the state’s Prioritization for Urgency of Need for Services Medicaid waiting list. These are Illinoisans who, for a variety of reasons, need care beyond what Medicaid currently provides for them and have applied for additional services, such as in-home care. They are children with developmental disabilities, seniors, individuals with severe mental illnesses, and more – people Medicaid was intended to serve.
But, due to a lack of funding, these Illinoisans wait for the care they need. And while the state has been busy enrolling as many able-bodied adults as possible in the Medicaid expansion and not making the needs of these disabled and elderly Illinoisans a priority — new information from DHS shows the toll it’s taking.”

There’s been a wait list for this Illinois program since it was created in 1999. The data cited in the column show that between 2013 and 2015, the number of people on the Illinois wait list actually decreased from about 22,000 to 18,000.

Nearly all of the Obamacare Medicaid expansion was paid by the federal government, so it’s totally separate from the state waivers that pay for the optional services when people get off the wait list. The expansion and wait list populations are separate, and expansion doesn’t necessarily affect the wait list population.

There is no strong evidence that the new adult group covered by Medicaid expansion is crowding out elderly and disabled beneficiaries on the wait lists, according to the Medicaid and CHIP Payment and Access Commission (MACPAC), a nonpartisan legislative branch research agency.

Most expansion states (20 of 30) either had no wait list for home- and community-based services or had a decrease in their wait list from 2014 to 2015, according to the Kaiser Family Foundation. Two states completely cleared their wait lists between 2014 and 2015.

The average increase in wait lists in non-expansion states was more than 2.5 times that of expansion states in 2014 and 2015, according to Kaiser. In fact, Cruz’s home state of Texas was one of two states that reported the longest waiting lists for such services in 2015 — even though Texas did not expand Medicaid.

Spokesmen for Cruz and Meadows did not respond to requests for additional comment on our analysis.

The Pinocchio Test

Cruz and Meadows argue that Obamacare expanded Medicaid to new non-elderly populations while other more vulnerable populations are being forced onto wait lists to get care. But the data do not confirm their suggestion that Obamacare expanded Medicaid at the expense of the wait list populations.

States can choose to keep specific people on wait lists for optional Medicaid services so that they can get care in their homes or communities, rather than being in an institution. But this population is separate from the ones who newly qualify for Medicaid under Obamacare. Further, the federal government paid for nearly all of the Medicaid expansion under Obamacare, so it’s unclear why it would have affected states’ capacity to move people off wait lists.

Data analyzed by the Kaiser Family Foundation show there’s no correlation between expansion states and the number of people on wait lists for home- or community-based care. In fact, Cruz’s home state of Texas, which did not expand Medicaid, is one of two states with the longest wait lists. Cruz and Meadows are free to argue that states should focus on decreasing their wait lists rather than expanding Medicaid eligibility, but there’s just not enough evidence that the two populations have much to do with each other.

Four Pinocchios

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"Too often now, these people and their families have been forced onto waiting lists while money has poured into the expansion population."
in an op-ed in the Wall Street Journal
Wednesday, March 15, 2017