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County Solutions and Innovation Blog​​
August 12
ACA Implementation Checkup

​Written by Kathryn Murphy​, Senior Research Associate.


This October, Americans will be able to enroll in health insurance plans through the newly created state-based health insurance Marketplace – formerly known as “exchanges.” In addition, depending on the state they live in, more Americans may qualify for coverage under Medicaid expansion.  The Patient Protection and Affordable Care Act (ACA), signed into law in 2010, made possible these new health insurance coverage mechanisms.  This expansion will have a significant impact on counties as county governments provide health care services to many of their residents.  

Counties in a number of states are required by state law to provide health services to low-income, chronically ill and uninsured people.  The ACA will help alleviate this burden. Individuals with incomes between 100 and 400 percent of the federal poverty level may be eligible for federal premium tax credits to help pay for private health insurance.  Through the state-based Marketplace, Americans can compare insurance options by price, benefits and quality to find the plan that best suits their needs. According to the Advisory Board Company, 17 states will operate their own Marketplaces, seven states are collaborating with the federal government to operate the Marketplaces, and the federal government will operate the Marketplaces in the remaining 26 states.

Map. State Action on the Medicaid Expansion, as of July 1, 2013 and
the State Requirement for County Contribution to Medicaid

Source: Kaiser Family Foundation, Status of State Action on the Medicaid Expansion Decision, as of July 1, 2013; Kaiser Commission on Medicaid and the Uninsured, Medicaid Today; Preparing for Tomorrow: A Look at State Medicaid Program Spending, Enrollment and Policy Trends, 2012.
Note: The 2012 Kaiser survey of the matching requirements for counties indicate 22 states with this requirement. However, as of July 1, 2012, all Iowa Medicaid services are the responsibility of the state.

Not all states will participate in the Medicaid expansion.In 2012, the U.S. Supreme Court let states decide whether to expand  Medicaid to individuals under the age of 65 with incomes up to 133 percent of the federal poverty level.  According to the Kaiser Family Foundation, as of July 2013, 24 states are moving forward with the Medicaid expansion – including Arkansas and Iowa with alternative expansion plans, 21 states are not moving forward with the expansion, and six states still debating .  In the 21 states in which counties are required to contribute to Medicaid, 10 states are moving forward with expanding eligibility for Medicaid, eight states are not moving forward on expansion, and three states – New Hampshire, Ohio, and Pennsylvania – have not decided yet.  In 2012, the state of Iowa assumed responsibility of funding the non-federal share of Medicaid away from counties.  While counties in states that are opting for Medicaid expansion may encounter additional costs with the enrollment, service delivery and coverage, counties in states that opt out of expansion may continue to pay for those who would have qualified under the Medicaid expansion and do not enroll in the Marketplace. 

The state-by-state Medicaid expansion and the introduction of subsidized plans through the Marketplace will give a significant number of people access to health insurance.  In King County, Wash. alone, more than 180,000 residents – nearly 85 percent of the county’s uninsured adults – will be eligible for Medicaid or reduced premiums for insurance through the Marketplace.  Of this total, about 83,000 will become eligible for Medicaid, including around 7,000 individuals who are currently homeless.  An additional 100,000 may be eligible for subsidized health plans through Washington state’s Marketplace, according to the Washington HealthPlanFinder            

With all of the potential additional coverage, the ACA implementation will pose challenges to counties. Since counties are creatures of the state, the impact of the ACA will vary by the counties’ responsibilities outlined by the state and the state’s decision regarding the Medicaid expansion and the operation of the Marketplace.  As we will explore in a future piece, ACA will also affect counties as employers of 3.3 million Americans. With innovation and leadership, county officials can meet these challenges to serve the health care needs of the community.


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