








































The Limits of Medicaid Reform in Pennsylvania


COMMONWEALTH, Volume 18, Issue 2 (2016). © 2016 The Pennsylvania Political Science Association.  
ISSN 2469-7672 (online). http://dx.doi.org/10.15367/cjppp.v18i2.112. All rights reserved.

The Limits of Medicaid Reform 
in Pennsylvania

 

Thinking Regionally about Access to Insurance  

and Health Care under the Affordable Care Act

MICHELE MOSER DEEGAN
Muhlenberg College

A. LANETHEA MATHEWS- SCHULTZ
Muhlenberg College

States’ varied decisions with respect to Medicaid expansion under the Afford-
able Care Act have drawn significant attention to questions about equity across 
states. Missing from the conversation is consideration of the varied impact that 
reform will have within states. This article considers how low- income Pennsyl-
vanians will fare under Medicaid expansion. Although Medicaid reform has 
already expanded access to insurance to significant numbers of low- income 
residents in the state, improvements in access to health care are mediated by 
pre- existing regional inequalities in social determinants of health and by Penn-
sylvania’s system of health governance. Drawing on lessons gleaned from the 
literature on regionalism, and examples of success in states that have adopted 
regional approaches to health delivery, we offer a theoretical approach for 
thinking regionally in Pennsylvania by building opportunities and capacities 
for cross- jurisdictional approaches to health and health care access.

The Patient Protection and Affordable Care Act (Public Law 111–148 
[123 Stat. 119 (2010)] [ACA]), is designed to make the health care sys-
tem more effective and efficient, while expanding insurance coverage 

and preventative care to millions of Americans. The ACA alters the existing 
health care system by expanding the regulatory role of the federal and state 



4 Michele Moser Deegan anD a. lanethea Mathews- schultz

governments and by requiring insurers and health care providers to restruc-
ture their personnel and services to accommodate the requirements of the law. 
Not only is “Obamacare” the most significant health care overhaul since 1965, 
when Medicaid and Medicare were instituted, but the ACA also provides a 
unique window for examining the politics of implementation of federal policy 
reform across a diverse and fragmented nation.

Extending Medicaid to uninsured low- income citizens is a key mechanism 
of the ACA. As originally conceived, starting in 2014, an expanded Medicaid 
extends coverage to all individuals under 65 years of age with incomes up to 
138% of the federal poverty level (Kenney et al. 2012).1 The federal government 
is picking up 100% of the costs of new enrollees initially, reducing its contri-
butions to these costs to 95% in 2016, and to 90% in 2020. The original ACA 
required states to expand Medicaid under threat of loss of all federal Medicaid 
reimbursements for existing enrollees.2 In National Federation of Independent 
Business et al. v Sebelius, Secretary of Health and Human Services, et al. (2012), 
however, the Supreme Court held that, because Congress’s tax and spend pow-
ers do not extend to compel the states to enact or administer federal regula-
tory programs, the mandated Medicaid expansion was unconstitutional. The 
Court’s decision, in short, made Medicaid expansion, and therefore also full 
implementation of the ACA, a matter of state choice.

States’ varied decisions with respect to Medicaid expansion have drawn 
significant attention to questions about equity across states (for example, 
Jacobs and Callaghan 2013). To be sure, since Medicaid’s inception in 1965, 
states have been required to comply with federal criteria—determining, for 
example, who receives care and what funds are provided at what costs—as a 
condition of receiving federal Medicaid funds. However, eligibility require-
ments, scope and breadth of services and benefits, and share of Medicaid 
funding provided by the federal government vary widely across states. As of 
June 2015, 30 states (including DC) have opted into adopting the ACA Medic-
aid expansion, 19 have opted out, and 2 remain undetermined (Kaiser Com-
mission 2012). Medicaid reform is a divisive issue; all of the states opting out 
are Republican- led (although 10 states had Republican governors when they 
decided to expand) and no states in the Deep South are expanding, making 
Medicaid reform regionally concentrated.

Missing from the national conversation about ACA outcomes is consid-
eration of the varied impact that reform will have within states. States have 
diverse systems of health governance that are not inconsequential to health 
outcomes. This is especially true for low- income residents who face the greatest 
obstacles not simply to obtaining health insurance, but to accessing preventive 



The Limits of Medicaid Reform in Pennsylvania  5

care, clinical care, and other health services. In this context, Pennsylvania is 
uniquely situated for two reasons. First, it is one of only a handful of states 
that has a mixed, or hybrid, health governance structure the consequences 
of which remain uncertain alongside ACA reforms.3 Second, Pennsylvania’s 
eligibility requirements for Medicaid prior to Obamacare were among the 
most restrictive in the nation, positioning the state to exponentially expand 
Medicaid enrollees and thereby significantly alter the landscape of health 
within its borders. The state of Pennsylvania has a vested interest in improv-
ing health for Medicaid enrollees, as they accounted for close to a quarter of 
the state’s population prior to Obamacare. Politically speaking, Pennsylvania 
is also somewhat unusual, having first opted out of the federal expansion in 
favor of a state- run demonstration project, only to quickly reverse course a few 
months later following a change in control of the governor’s office.

How will low- income Pennsylvanians fare under ACA Medicaid reform? 
It is certain that hundreds of thousands of previously uninsured residents 
will gain health insurance, but consequences for health care and health out-
comes among the population are less clear. In this article, we take stock of 
Medicaid reform in Pennsylvania with three goals in mind. First, after a brief 
historical review of the political context behind the state’s labored decision 
to expand Medicaid, we provide a sketch of reform outcomes to date, focus-
ing on low- income residents’ access to health insurance. Health insurance is 
a precursor to, not the equivalent of health. Therefore, our second goal is to 
explicate barriers to health among low- income Pennsylvanians—barriers that 
include geographical variation in access points to primary health care. Where 
low- income residents can access health is determined in part by social and 
economic conditions of unemployment, poverty, transportation, and housing. 
It is also determined by the structure of health governance within the state 
and it is this latter variable that holds our primary interest. Not only does the 
ACA largely sidestep these interdependent determinants of health inequality, 
but by centralizing the administration of health, the governance structure of 
Pennsylvania state health may exacerbate health inequalities. Thus, our third 
goal is to suggest a theoretical framework for approaching health regionally 
in Pennsylvania, one that is open to reforming administrative structures of 
health governance to focus on regional, cross- jurisdictional approaches to 
public health and health care access. Absent more comprehensive reform of 
the state’s public health system that considers regional variation in the con-
ditions that facilitate health, Medicaid reform will provide access to health 
insurance but, by itself, not necessarily better health outcomes for low- income 
Pennsylvanians.



6 Michele Moser Deegan anD a. lanethea Mathews- schultz

Political Prelude

One of the 26 states party to National Federation of Independent Businesses v 
Sebelius, Pennsylvania initially declined to participate in the federal Medicaid 
expansion. Following a delayed response to the Court decision, Pennsylva-
nia Republican governor Tom Corbett led his administration in developing a 
state- run alternative to the federal expansion to pay private insurers to cover 
the uninsured using newly available Medicaid funds.4 After negotiating for 
over a year with the Obama administration, the Centers for Medicare and 
Medicaid Services (CMS) granted Pennsylvania a federal waiver in August 
2014, enabling the Corbett administration to modify the state’s existing Med-
icaid program to expand access to health insurance to adults with incomes 
up to 133% of the federal poverty level. Corbett’s plan, Healthy Pennsylva-
nia, could enroll up to 600,000 new citizens for health care coverage begin-
ning January 1, 2015. Healthy Pennsylvania had two core components. First, 
it modified the state’s existing Medicaid program through changed benefit 
plans, implementation of cost- sharing premiums, and establishment of incen-
tives to encourage healthy behaviors. Second, adults previously ineligible for 
Medicaid but newly eligible under the ACA’s expanded requirements could 
gain access to health insurance through private managed health plans, or Pri-
vate Care Option service delivery systems.5

Among the most controversial of these changes were cost- sharing stip-
ulations and eligibility requirements linking health insurance access to 
“employment related activities.” The demonstration project approved by CMS 
permitted the state to charge monthly premiums for individuals with incomes 
up to 100% FPL during year two not to exceed 2% of household income (dur-
ing the first year of the demonstration, no premiums were charged). Indi-
viduals with incomes below 100% FPL could also be charged copayments in 
some circumstances. After year one of the demonstration project, individu-
als could reduce their cost sharing responsibilities by demonstrating healthy 
behaviors—including, for example, annual wellness exams and an established 
record of timely copayments.6 In its original formulation, Healthy Pennsyl-
vania linked health insurance eligibility for able- bodied adults, ages 21–64, 
working fewer than 20 hours per week to proof of engagement in “employ-
ment related activities,” such as job training. Political contingencies eventu-
ally forced Corbett to weaken these conditions, such that the CMS waiver 
stipulated that “health coverage provided by the Medicaid program and 
this demonstration will not be affected by” the state’s efforts to encourage 
employment through incentives to join training and work related activities.7

Early in his administration, Corbett criticized the ACA as “federal over-
reach” and referred to Medicaid as a “broken system,” arguing “it would 



The Limits of Medicaid Reform in Pennsylvania  7

be financially unsustainable for the taxpayers,” to participate in the federal 
expansion (Beeler 2013). At the same time, however, like many governors, 
Corbett faced political and budgetary pressures alongside large populations of 
low-i ncome residents lacking health insurance. Indeed, the Corbett Admin-
istration previously eliminated adultBasic, which had provided health insur-
ance for low-i ncome working adults ineligible for Medicaid, generating even 
greater need for affordable accessible health insurance. 

Corbett’s “private option” allowed the state to capitalize on additional 
federal funding without compromising conservative principles. One jour-
nalist referred to this approach, shared by Arkansas, Iowa, and Michigan, 
as “making Medicaid more Republican” (Ramsay 2015). Corbett claimed 
a political victory in securing “a plan that was created in Pennsylvania for 
Pennsylvania—a plan that would allow us to reform a financially unsustain-
able Medicaid program and increase access to health care for eligible individ-
uals through the private market,” (in Wenner 2014) but the political realities 
were more complicated. The CMS demonstration waiver imposed consider-
able restrictions on Healthy Pennsylvania, and ultimately, the state nudged its 
way toward expanding Medicaid with the help of federal funds.

Corbett’s Healthy Pennsylvania was criticized both within and outside of 
the state and its brief life was both cause and consequence of the electoral poli-
tics of the 2014 gubernatorial elections. The second half of Corbett’s first term 
saw declining public approval ratings (University of Virginia’s Larry Sabato 
characterized Corbett “the incumbent Republican governor most likely to lose 
in 2014” [in LaRosa 2013]). Corbett’s Administration was flanked by seem-
ingly endless bad news: drastic education cuts, teacher layoffs, controversial 
abortion legislation, poor job growth. His administration was also troubled 
by fallout from his own verbal gaffes and relative weak likeability compared to 
the Democratic challenger, Tom Wolf. One of the most watched gubernatorial 
elections of 2014, the Corbett campaign was heavily funded by the Republi-
can Governors’ Association; Wolf, CEO of a family-owned building materials 
business and former state revenue secretary, donated $10 million to his own 
campaign and received support of major labor and teachers’ unions in the 
state. Campaigning with a promise to revoke Healthy Pennsylvania in favor 
of expanding the state’s preexisting Medicaid program with support from 
ACA federal funds, Wolf secured victory with 55% of the vote. In what was 
characterized as an otherwise Republican friendly midterm election, Corbett 
became the first incumbent governor in Pennsylvania not elected to a second 
term (Olson and Esack 2014).

Despite his loss in November 2014, Corbett’s administration began imple-
mentation of Healthy Pennsylvania in January 2015. At the time of Wolf ’s 



8 Michele Moser Deegan anD a. lanethea Mathews- schultz

inauguration that February, approximately 120,000 Pennsylvanians had 
already enrolled. True to his campaign promises, Wolf began transitioning 
the state away from the waiver program in early Spring 2015, toward tradi-
tional ACA Medicaid. With an intended completion timeline of September 
2015, Wolf announced that all individuals enrolled in Healthy Pennsylvania 
or eligible for Medicaid would be moved into the state’s pre- existing Medicaid 
managed- care plan, HealthChoices. Wolf reinstated benefit packages previ-
ously modified by the Corbett administration, while cost- sharing premiums 
and healthy behavior incentives—core components in Corbett’s original state 
demonstration project—were eliminated.

Medicaid Expansion in Pennsylvania

Perhaps the most significant anticipated effects of Medicaid reform in Penn-
sylvania (and elsewhere) will result from the expansion of coverage to pre-
viously uninsured and ineligible poor adults without dependent children 
(“childless adults” or “other adults”).8 Medicaid reform will also enroll more 
working parents, previously ineligible under restrictive state requirements. 
According to the Kaiser Commission, before the ACA, 33 states limited eligi-
bility for working parents below 100% of the federal poverty level (FPL)—in 
16 of those states, including Pennsylvania, eligibility was restricted to parents 
earning less than 50% of the FPL. Working parents with dependent children 
in Pennsylvania were eligible for Medicaid with incomes up to 99% of the 
federal poverty level; nondisabled adults without children were not eligible 
for Medicaid at all.9 Eligibility in Pennsylvania now includes all adults, ages 
21–64, with incomes up to 138% of the federal poverty level, equal to approxi-
mately $21,984 for a family of two in 2015.

What does Medicaid enrollment expansion in Pennsylvania look like so 
far? In 2014, Medicaid provided coverage for approximately 2.2 million Penn-
sylvanians, including approximately 1.1 million adults and 1.1 million children. 
At the start of 2015, state officials estimated that 600,000 additional residents 
would be eligible for health insurance under an expanded program. Between 
January and July 2015, the state’s Medicaid program, HealthChoices, added 
440,000 new enrollees (including the approximately 120,000 residents who had 
been enrolled in Corbett’s short- lived state- run alternative).10 As seen in Figure 
1, total Medicaid enrollment in Pennsylvania grew to more than 2.5 million by 
July 2015. Among adults, Medicaid enrollments increased by 18% within one 
year, jumping from 1,137,635 in June 2014 to 1,391,534 in June 2015.

Appendix A and Figure 2 contain additional information about Medicaid 
enrollment both before and after the ACA expansion by county. Appendix A 



The Limits of Medicaid Reform in Pennsylvania  9

also provides the best available information about the population of each 
county most likely to benefit from new Medicaid requirements—adults living 
at or below 139% of the federal poverty level just before the Medicaid expan-
sion took effect.11 Close to 1.4 million adults ages 18–64 were living under 
139% FPL in 2013 across the state, and approximately 400,000 of those were 

Note: “Adult” in this figure refers to individuals ages 21 to 64.

Figure 1. Statewide Total and Adult Medicaid Enrollment, April 2014 to July 2015. (Pennsylvania 
Department of Human Services.)

Figure 2. Percentage Change in Medicaid Enrollment ages 18–64 from 2014 to 2015. (U.S. 
Census Bureau, American Community Survey, 2008–2013; Pennsylvania Department of Health; 
and Pennsylvania Association of Community Health Centers, Community Health Center Directory, 
2015.)



10 Michele Moser Deegan anD a. lanethea Mathews- schultz

uninsured. As is to be expected, the most populous counties in the state report 
the highest real numbers of poor uninsured adults, including most notably 
Allegheny and Philadelphia Counties. But, counties vary in the proportion 
of poor uninsured adults relative to overall county populations. For example, 
Pike County is a relatively small county with an overall population of 56,414 
and a small population of poor adults, 5,000 individuals. Close to 37% of Pike 
County’s poor adults are uninsured, however, exceeding the statewide average 
by more than 8 percentage points.

Pennsylvania tracks and records total Medicaid enrollments by county 
each month, but unfortunately, the state does not report the numbers of 
enrollees newly eligible after 2015. Thus, monthly enrollment figures include 
previously enrolled Medicaid recipients in addition to newly enrolled.12 While 
the data reported in Appendix A and Figure 2 are not perfect, they provide 
a partial window into changes at the county level and statewide variation as 
a result of Medicaid expansion. The state as a whole experienced an almost 
19% increase in adult Medicaid enrollment between June 2014 and June 2015. 
Increases within the counties range from a high of 28% in Pike County to 
a low of 12% in Montour County. In Pike, as in other darker shaded coun-
ties in the east and southeastern regions, Medicaid enrollment increased 
from 2014–2015. Most of the counties with higher percentages of Medicaid 
enrollees are those with a higher percentage of previously uninsured, sug-
gesting that Medicaid expansion is having the intended effect of expanding 
insurance to many poor individuals. Because we say more about the Lehigh 
Valley region of Pennsylvania below, it’s worth noting Medicaid expansion 
in this region. Combined, Lehigh and Northampton Counties include about 
630,000 residents and about 61,000 of these are adults living in poverty. In 
2013, 19,737 adults living in poverty in this region lacked health insurance. 
Lehigh County experienced a 22% increase in Medicaid enrollments since 
2015; in Northampton, the increase has been about 24%. While these num-
bers are encouraging, as we explore further below, access to insurance is no 
guarantee of improved access to health care, particularly in a context defined 
by intra- state and inter- regional inequalities in both social determinants of 
health and availability of access points to care.

Thinking beyond Insurance: Health Governance  
and Regional Health Care Inequality

States’ pre- ACA structures and processes for administering Medicaid and 
other health related programs provide a critical context for considering imple-
mentation of Medicaid reform under Obamacare. Indeed, the contours of 



The Limits of Medicaid Reform in Pennsylvania  11

Medicaid prior to the ACA were in many ways the result of states’ interests and 
financial incentives, which collectively helped propel the program’s evolution, 
decoupling it from welfare and relaxing eligibility rules in the 1980s (lead-
ing to exponential increase in enrollment) and transitioning (in a majority of 
states) to managed care plans in an effort to reduce costs in the 1990s. In 2010, 
Medicaid expansion was the most politically palatable option for expanding 
health insurance coverage not only because it is less costly than other options, 
but also because it is a state- administered program (Brecher and Rose 2013). 
The state of Pennsylvania’s decision to adopt federal Medicaid reform is likely 
the result of both shifting political fortunes (most notably a radical ideological 
change in the state executive office coupled with public opinion and pressure 
from health providers and insurers) and financial incentives (the state Depart-
ment of Health estimates that cost savings will exceed $626 million in the first 
year and more than $645 million in the second year alone).

The potential of Medicaid expansion to succeed in increasing access to 
insurance and to health care for low-i ncome Pennsylvanians will be shaped 
in part by the structure of health governance and the relationships between 
state and local governments. The states’ Medicaid program, HealthChoices 
(previously Medical Assistance) is administered through the office of Medical 
Assistance Programs, an office within the state Department of Human Ser-
vices. Eligibility and program requirements are administered through county 
assistance offices. Medicaid recipients are enrolled in one of several managed 
care organizations (MCOs) in the state, operating throughout five “zones” 
within the state.

Although the Department of Human Services administers Medicaid 
through its Office of Medical Assistance Programs, the Department of Health 
coordinates health resources in the state. Pennsylvania is one of just a handful 
of states in the nation characterized by a “hybrid” governmental model, that 
is, it contains both independent local health agencies and state-run health 
offices (Salinsky 2010).13 Public health programs are overseen by the Bureau of 
Community Health Systems (BCHS) in a complex network of district offices 
and state health centers organized into six health districts. As shown in Figure 
2, the state operates health centers in 61 of Pennsylvania’s 67 counties. These 
are directly funded by the state and managed by state employees. State health 
centers provide health screenings, diagnoses and clinics to prevent commu-
nicable diseases, immunizations, chronic disease prevention, health and envi-
ronmental education programs, and counseling.

In addition to state-funded health centers, Pennsylvania’s network of pub-
lic health includes six county health departments in Erie, Allegheny, Chester, 
Bucks, Montgomery, and Philadelphia Counties and four local health bureaus 



12 Michele Moser Deegan anD a. lanethea Mathews- schultz

in the municipalities of York, Wilkes- Barre, Bethlehem, and Allentown. 
County Health Departments and Municipal Health Bureaus are creations of 
Pennsylvania Act 315, the Local Health Administration Law, which allows 
(but does not require nor incentivize) local governments to create their own 
localized departments in return for greater control over decisions about avail-
able services and community partner collaborations. County Health Depart-
ments and Municipal Health Bureaus are accountable for meeting state and 
federal public health provisions; they receive state funding but can also raise 
revenues through local taxation, service fees, and external grants. Staffed 
by local government employees, County Health Departments and Munici-
pal Health Bureaus typically offer expanded public health services and work 
closely with community health providers. Prior to Obamacare, County Health 
Departments and Municipal Health Bureaus proved especially important for 
providing preventive services and primary care to individuals ineligible for 
Medicaid, and for providing services insufficiently covered by private provid-
ers. For example, the Bethlehem Health Bureau provides free individual and 
group counseling on weight loss, diabetes, hypertension, high cholesterol, and 
smoking cessation for residents of Bethlehem. Similarly, the Allentown Health 
Bureau is part of a community wide effort, Healthy Kids Healthy Allentown, 
which promotes good nutrition and physical activity programs for children 
under 18 years of age.

Of course, government organizations are not the only entities in public 
health. Private and nonprofit organizations are critical partners in the deliv-
ery of health care and the extension of services to low- income populations. 
Most significant for our purposes, community health centers, including 
those designated as Federally Qualified Health Centers (FQHCs) and Rural 
Health Clinics (RHCs), are a primary source of care and preventive services 
for Medicaid enrollees and the uninsured and, with increased federal fund-
ing provided through the ACA, will continue to serve as a significant source 
of primary care for low-i ncome populations. FQHCs and RCHs are nonprofit 
organizations, supported by federal and state funds that provide preventive 
primary health services under section 330 of the Public Health Service Act. 
They may provide services such as primary medical, dental, and behavioral 
health care regardless of a patient’s ability to pay. As shown in Figure 2, there 
are currently over 260 sites in Pennsylvania located in 45 of Pennsylvania’s 
67 counties, serving approximately 700,000 individuals (Community Health 
Centers, 2015). In addition to these organizations, there has been an increase 
in the number of private care centers, such as Patient First, as well as drop- in 
care centers run by area hospitals. While the apparent influx of new enti-
ties is encouraging, in most cases, this patchwork health care delivery system 



The Limits of Medicaid Reform in Pennsylvania  13

continues to lack comprehensive coverage for hospitalization, long- term care, 
and emergency care as well as dental care, eye and vision care, and mental 
health services. Likewise, little is known about the extent to which private-
sector health clinics are helping to fill delivery gaps, especially for the Med-
icaid population.

In the best case scenario, Pennsylvanians still lacking health insurance 
or without easy access to primary care through a private provider can receive 
primary care through FQHCs or a similar organization, reducing the risk 
and prevalence of preventable diseases, which in turn will reduce the cost 
of care as individuals will be treated earlier and require less hospitalization. 
However, this assumes that FQHCs, or their equivalent, are located in areas 
accessible to these individuals. Returning to Figure 2, most FQHCs and RHCs 
are concentrated in the urban core of Philadelphia and in far western Pennsyl-
vania, even though there have been larger increases in Medicaid enrollment 
in south- central and northeastern counties. Figure 3 provides complementary 
information about the geographic distribution of the ratio of the population to 
primary care physicians using the Robert Wood Johnson Foundation’s County 
Health Rankings and Roadmap data (www.countyhealthrankings.org). These 

Figure 3. Primary Care Physician Ratio by County. (Robert Wood Johnson Foundation County 
Health Rankings and Ratings; Pennsylvania Department of Health; and Pennsylvania Association 
of Community Health Centers.)



14 Michele Moser Deegan anD a. lanethea Mathews- schultz

data include primary care physicians specializing in medicine, family med-
icine, internal medicine, or pediatrics and provide a measure of the avail-
ability of health care and access to providers. As shown, many counties with 
higher ratios of population to primary care physicians (those shaded darker 
on Figure 3), also have few if any FQHC/RHCs, potentially forcing residents 
to forgo preventive care, or to seek out hospital emergency rooms for non- 
emergent care. Comparing Figures 2 and 3 further emphasizes the need to 
consider more access to preventative health care for low-i ncome residents. 
For example, counties such as Pike, Perry, Monroe, and Bedford, which lack 
a sufficient number of physicians to serve the overall county population, also 
lack federally assisted health centers for low-i ncome residents and have seen 
higher increases in Medicaid enrollment. Clearly, there is a need to consider 
a better way to organize health services for low- income individuals living in 
these regions.

While these figures suggest that the state’s hybrid system of health gov-
ernance promotes horizontal equity in some respects—nearly every county 
has a state-run health center, for example—it is clear that there is consider-
able variation in the extent of need among low-i ncome residents across coun-
ties and in structural and environmental factors across the state. In short, 
low- income Pennsylvanians faced varied access to primary health care. As 
suggested above, the increase in insured adults as a result of Medicaid expan-
sion could lead to greater health inequality, as those lacking access to health 
services, due to a limited number of physicians or facilities, maintain their 
current level of health while those living in areas with more options for health 
care have greater access. Additionally, previously insured individuals may face 
difficulties scheduling health care visits due to the increase in demand and 
limited supply of health care workers.

The remainder of our article suggests a theoretical way of thinking region-
ally to derive the greatest benefit from the ACA’s twin promise of improving 
health insurance and health care for low- income Americans.

Seeking Regional Solutions to Health Challenges  
in Pennsylvania

The ultimate success of the ACA will depend in large part on the willingness 
and ability of states, health insurers, and health care providers to transform 
the existing health care system. Because federally designed Medicaid reform 
relies on states to run and implement the expansion, it is inherently linked 
to a preexisting landscape of health inequalities, socioeconomic disparities, 
inequalities in the social determinants of health, and varied obstacles to care. 



The Limits of Medicaid Reform in Pennsylvania  15

In this context, location matters, as health is shaped by many factors that 
lie outside the boundaries of health care, including access to employment 
opportunities, adequate transportation, environmental issues such as air 
and water quality, and racial equity. Literature in the field of regionalism, for 
example, suggests that neighborhood access to healthy food, concentrations 
of poverty within geographic regions, and resource disparities within larger 
regional contexts are all factors that affect health outcomes at both individual 
and community levels (e.g., Hutson et al. 2012; Lynch et al. 1998). Moreover, 
individuals rely on their local communities for health care; therefore, mea-
surement of the ACA’s success must include consideration of the equity, acces-
sibility, and affordability of services within more localized areas.

A regional boundary is defined by where people reside, travel, work, shop, 
and play (Hamilton 2014; Miller 2002). The recognition that municipalities 
within a region are interdependent is now commonplace within research and 
practitioner communities (Dreier et al. 2004; Hamilton 2014; Ledebur and 
Barnes, 1993; Orefield 2002; Pastor et al., 2000; Rusk 2003; Savitch et al. 1993; 
Savitch and Vogel 2000; Swanstrom et al. 2002). While there is debate about the 
extent and direction of this interdependency, a regional perspective is critical 
for understanding social disparities and economic growth at the local govern-
ment level. Regions present unique governing challenges because they typically 
include multiple local governments and often lack static legal boundaries.

The subject of health equity itself is well traversed—scholars and practi-
tioners have long drawn attention to issues related to population health: racial 
and ethnic disparities in health and health care, state and local policy efforts 
to alleviate health disparities; the interconnectedness of residential segrega-
tion, lack of access to health care, environmental stressors (such as violence), 
and community infrastructure (e.g., Institute of Medicine 2011; Kirby and 
Kaneda 2005; Lynch et al. 1998; Schulz et al. 2002). These findings are increas-
ingly considered in the context of regionalism; indeed a recent Policy Link 
report suggests, “much of the innovative work around health and regional 
equity is occurring at the intersection between health and other areas such as 
transportation, housing, and economic opportunity” (2002, 23). Past research 
has linked race- based residential segregation and socioeconomic status to the 
social and material resources that promote health and limit disease (Schulz 
et al. 2002).

Most critically for our purposes, studies of healthcare utilization suggest 
that an individual’s decision to access primary health care services depends 
upon spatial considerations, including regional availability and regional acces-
sibility and aspatial factors such as income, race, ethnicity, education level, or 
sex (Wang and Luo 2005). Of particular importance, researchers estimate that 



16 Michele Moser Deegan anD a. lanethea Mathews- schultz

individuals are more likely to access services within a 15- mile radius or not 
exceeding a 30- minute barrier (e.g., Luo 2004; Wang and Minor 2002).

While Medicaid expansion has already significantly expanded access to 
health insurance for more than 400,000 low- income Pennsylvanians, far sur-
passing the numbers of individuals who have enrolled in individual insur-
ance plans through the federal marketplace, our concern is the next step, how 
to ensure access to preventive and primary care for low- income individu-
als with or without health insurance. Translating gains in health insurance 
into healthier residents and greater health equity across the state will require 
coordinated regional strategies. These strategies include changing state health 
governance structures to establish a more decentralized public health system, 
one that allows for regionalized implementation and state support for new 
collaborative regional health care systems.

For example, recent research suggests that centralized, state- run health 
governance systems—such as the system characterizing health governance 
in Pennsylvania—are associated with the lowest health outcome measures on 
several dimensions of health, including adult smoking, low birth weight, teen 
births, and preventative screenings for breast cancer and diabetes (Hays et al. 
2014). One of the benefits of the U.S. system of federalism is the ability to learn 
from state- level variation in public health delivery systems. Here, we briefly 
draw on Minnesota and Massachusetts, two states consistently ranked among 
the healthiest in the nation by the United Healthcare Foundation and Asso-
ciation of State and Territorial Health Officials. Like Pennsylvania, both states 
have histories rooted in strong local governance. Unlike Pennsylvania, both 
Minnesota and Massachusetts have integrated regional approaches to public 
health through statewide planning that emphasizes devolving accountability 
and health delivery planning to local governments with state-level oversight 
and support.

Regional Public Health in Minnesota

In Minnesota, the Community Health Services system has been in place since 
1976, when the state passed the Community Health Services Act (Minn. Stat. 
§ 145A), now called the Local Public Health Act. Unlike Pennsylvania’s Act 
315, which permits, but does not require, counties and municipalities to cre-
ate health departments, the state of Minnesota designates Community Health 
Boards (CHBs) as the legal governing authorities for local public health. CHBs 
can be multi- county, single- county, or city- based but must serve a mini-
mum population equal to 30,000 people (Minnesota Department of Health 
2016). CHBs are better positioned to tailor health services to fit the needs of 

mailto:Minn.States.@154A
mailto:Minn.States.@154A


The Limits of Medicaid Reform in Pennsylvania  17

a smaller population than is possible with a state-governed structure. Fund-
ing for CHBs is provided through a mix of federal, state, and local funding as 
well as fees and reimbursements. Non- categorical state funding provides the 
base funding for the CHBs in addition to targeted funding to address state-
level public and community health priorities (Mays and Frauendienst 2014). A 
recent report measuring performance indicators on CHBs suggests that many 
work with local partners to increase health education programming, particu-
larly in school settings. Also, most engage in activities to promote healthy 
behaviors, particularly nutrition and physical activity (Minnesota Depart-
ment of Health 2014). Other program areas include maternal and child health, 
infectious disease prevention, and promotion of environmental health, such 
as radon testing.

One of the challenges faced by Minnesota CHBs is funding. Even though 
the state provides significant governmental transfers, many CHBs struggle to 
provide sufficient local tax and non- tax revenue (Minnesota Department of 
Health 2015). Changes in population demographics, including the decline of 
rural populations, are another concern. In spite of these challenges, evidence 
suggests that there is increasing ability for CHBs to meet state performance 
standards and the state is encouraging all CHBs to apply for Public Health 
Department Accreditation, which would provide additional technical support 
and research to improve service delivery. Minnesota’s CHBs provide decen-
tralized health centers with strong support from the state, providing residents 
more targeted services and programming to meet the unique needs of each 
region.

Regional Public Health in Massachusetts

If states such as Minnesota provide empirical support that legislative and 
administrative decentralization may help improve community health, Mas-
sachusetts provides an example of the benefits of engaging public and private 
services providers in regionalizing public health. Massachusetts is both one of 
the healthiest states in the nation and characterized by one of the most decen-
tralized systems of health. Historically, each municipality was responsible for 
providing public health services and acted as the primary funder for these 
services. In fact, until 2006, state law did not provide for the opportunity for 
any direct funding for public health. With over 300 communities and varying 
degrees of financial capacity, state leaders recognized that the existing system 
was no longer sustainable and that a more centralized approach, with greater 
state-level engagement, was needed to ensure equitable access to care for all 
citizens.



18 Michele Moser Deegan anD a. lanethea Mathews- schultz

Following on the heels of the landmark Massachusetts health reform that 
was the precursor to the ACA, local health department and state officials 
prepared a report recommending several improvements to the public health 
system (Hyde and Tovar 2006). These recommendations, along with further 
study of the problems by public health leaders, led to the creation of several 
additional policy changes. First, in December 2006 the state launched the 
Massachusetts Public Health Regionalization Project with the goal of estab-
lishing consortiums of local health departments across multi- jurisdictional 
boundaries to provide a “consistent standard of care and equal level of ser-
vices.” (Massachusetts Public Health Regionalization Project 2016). Six 
regional consortiums received Public Health District Incentive Grants from 
the state, supported by a grant from the U.S. Center for Disease Control. These 
consortiums bring together local health boards and community health care 
provides to create regional health improvement plans and coordinate services. 
For example, the Central Massachusetts Regional Health Alliance, compris-
ing seven local health boards and over 90 community organizations and hos-
pitals, developed a strategic plan that includes a focus on health equity and 
health disparities (Central Massachusetts Regional Public Health Alliance 
2014). Second, to further enable and encourage regionalization, in 2008 state 
policy makers revised Chapter 529, an Act Relative to Public Health Reorgani-
zation, which removed barriers to regionalization. This law provides the legal 
basis for state funding for public health but retains legislative prerogative for 
development of the funding formula and subsequent annual funding. Third, 
in 2013, Massachusetts created the Office of Local and Regional Health, the 
hub for partnerships between the state Department of Health and Human 
Services and regional consortiums.

This office is similar in scope to Pennsylvania’s Bureau of Community 
Health Systems. The evolution of the expansion of state efforts to support 
the new regional collaborative and local health boards is still relatively new. 
However, research by the Institute of Community Health points to early posi-
tive outcomes in the District Incentive Grant Program and regional health 
consortium (Hays et al. 2014).

Opportunities for Regionalizing Public Health  
in Pennsylvania

Our goal here is not to suggest a one size fits all approach. To be sure, Mas-
sachusetts and Minnesota are significantly different both from each other 
and from Pennsylvania culturally, politically, geographically, and economi-
cally. Rather, our goal is to draw attention to the experiences in Minnesota 



The Limits of Medicaid Reform in Pennsylvania  19

and Massachusetts, and to emergent research on public health governance, 
to suggest that thinking regionally offers innovative routes for improving 
health care and population health outcomes. Pennsylvania is well positioned 
to encourage greater decentralization of public health by revising existing leg-
islation to encourage a regionally driven public health system. For example, 
policymakers could consider revising Act 315 to provide greater incentives for 
counties and municipalities to create local health departments and multijuris-
dictional health departments that include two or more counties as a regional 
economic entity.

Regional health departments are beneficial for several reasons. First, by 
design, they would be attuned and responsive to residents within identified 
geographies, including at- risk populations in cities and suburbs. Currently 
operating Health Bureaus offer more expanded clinical services, environmen-
tal health, and targeted community education opportunities to residents than 
do state-run health centers and are more adaptable to local community issues. 
Regional health departments, we expect, would provide the same attention 
to community needs. Second, regional health departments would increase 
community engagement in public health. Act 315 requires that county com-
missioners appoint five residents within a health department’s geographic 
boundary to serve on a Board of Health, ensuring greater localized autonomy 
over public health provisions than is current practice in most counties in the 
state. The third benefit is that localized health departments would provide 
opportunities for greater coordination of regional health services including, 
for example, county departments of Human Services in the areas of mental 
health, aging, and children and youth services. Regional health departments 
would also have greater ability to coordinate services directly with nonprofit 
and private providers to improve regional health as shown through the exam-
ples of CHBs and Regional Health Departments in Massachusetts.

If regionalizing Pennsylvania’s approach to health is a good idea, and we 
think it is, there are important funding, cost, and political considerations (we 
say more on this below). A large question, in light of current state budget woes, 
is funding. Deeper consideration of the cost of implementation is necessary; 
however one assumption is that expenditures for state health centers would 
be shifted from the current state health centers, which would no longer be 
needed, to the new regional entities. Further funding would be raised through 
local sources, federal grants, and service provision.

An even more politically feasible and practical step toward thinking 
regionally is to encourage growth and proliferation of FQHC/RHCs and sim-
ilar organizations providing community-level primary care. FQHC/RHCs 
receive funding from the Health Resources and Services Administration of 



20 Michele Moser Deegan anD a. lanethea Mathews- schultz

the U.S. Department of Health and Human Services. Maximizing the poten-
tial for federal funding by providing additional state funds to organizations 
operating within high- need locations would serve those most in need of 
affordable health services.

Combined, these efforts would provide a better foundation for reducing 
health disparities by recognizing the importance of regional health planning 
that includes collaboration with neighboring government entities as well as 
nonprofit and private-sector providers.

Regional Case Study of the Lehigh Valley

Figure 4 provides an example for thinking regionally in the way that we imag-
ine by examining the spatial relationships of public health offices and FQHCs 
in the Lehigh Valley region of Pennsylvania. The Lehigh Valley region com-
prises Lehigh and Northampton Counties, 62 municipalities, and 17 school 
districts. The Valley is home to approximately 600,000 residents, with median 
income ranging from $54,923 to $60,097. Approximately 14% of Lehigh 

Figure 4. Percentage Uninsured up to 138 FPL by Census Tract, Lehigh and Northampton 
Counties. (U.S. Census Bureau, American Community Survey, 2008–2013; Pennsylvania 
Department of Health; and Pennsylvania Association of Community Health Centers.).



The Limits of Medicaid Reform in Pennsylvania  21

County lives at 100 FPL; in Northampton, the poverty rate is just under 10%. 
Lehigh County is home to Allentown, the third largest city in the Common-
wealth, with a poverty rate of 28%. As shown in Figure 4, the state operates 
a health center in each county, while the cities of Allentown and Bethlehem 
have their own Health Bureaus. There is also an FQHC located in Allentown.

Given Allentown’s relatively high poverty rate, it is an obvious place to 
locate services designed to provide affordable health care. Nonetheless, closer 
examination of census tracts in the Lehigh Valley as a whole suggests there 
are other places in the region that would benefit from more accessible health 
care. Following Governor Wolf ’s expansion of traditional Medicaid, we would 
expect most areas on Figure 4 to show fewer uninsured over time, as more 
individuals register for HealthChoices in the coming years. Indeed, recall our 
discussion above and Appendix A, which shows that Lehigh and Northamp-
ton exceed the statewide average rate of change in Medicaid enrollments in 
the year stretching from June 2014 to June 2015. Lehigh’s Medicaid enroll-
ment increased by about 22%; in Northampton, the increase was almost 24%.

We expect that some of these individuals will now seek more frequent 
primary and preventative care. However, like many regions in the state, the 
Lehigh Valley is characterized by barriers to health care and improved health 
outcomes that cannot be overcome simply through the extension of health 
insurance. Community health needs assessments in the region conducted in 
compliance with the requirements of the Affordable Care Act have demon-
strated, for example, that transportation, housing, employment, and cultural 
and language barriers are important factors explaining disparities in health 
outcomes and access to preventive health services (Mathews 2012; Mathews- 
Schultz and Brill 2015). Further, the needs of residents living in the urban 
core areas of the Lehigh Valley differ from those living in the suburban and 
rural outskirts of the region; access (particularly for residents lacking trans-
portation) is particularly significant in the rural areas. Communities in the 
northern and southern tiers of the Lehigh Valley, for example, lack access to 
the region’s bus system, the only form of public transportation.

Interestingly, policy and county leaders in the Lehigh Valley previously 
took steps toward creating a bicounty health department in the region. Les-
sons from this experience reveal both the appeal of thinking regionally about 
health and the practical and political barriers to implementing regionalism 
without clear incentives and support from state (and possible) federal insti-
tutions. In 2010, several organizations within the health care community 
in Lehigh and Northampton Counties, including the two municipal health 
bureaus, Two Rivers Health Foundation, and the local hospitals, proposed 
the creation of a new bureau that would replace the existing Allentown and 



22 Michele Moser Deegan anD a. lanethea Mathews- schultz

Bethlehem Health Bureaus. That proposal was for a larger multicounty entity 
that would offer expanded services and new locations in Easton, Bangor, and 
Slatington, three areas with a large number of low-i ncome residents that tend 
to be underserved by the existing urban core health bureaus.

Unfortunately, despite empirical evidence that a bicounty health depart-
ment would better serve the health needs of the region’s low- income pop-
ulation, these efforts failed to gain enough political support among either 
Lehigh or Northampton County political elites and elected leaders who had 
to approve its creation. The main sticking point for the county commissioners 
and opponents of the regional health department stemmed from the proposed 
expectation that each county and the three cities would contribute resources 
to operate the new bureau. In the midst of the recession, and with Tea Party 
Republicans on both the Lehigh and Northampton county councils opposed 
to increasing the size of government, this requirement was not politically 
viable. It is likely that opposition to regional health bureaus will continue 
without state-level reforms to decentralize public health similar to those in 
Minnesota and Massachusetts and incentives to make it easier for regions to 
expand autonomy and accountability.

Moving Forward after Obamacare:  
Tentative Conclusions and New Questions

It is certain that large numbers of low- income previously uninsured Pennsyl-
vanians will gain health insurance as a result of the state’s Medicaid expansion. 
Early indications suggest that, in the first half of 2015, a far greater number 
of residents enrolled in HealthChoices—the newly designed and named state- 
run Medicaid program—than enrolled in the private health marketplace cre-
ated under Obamacare. It is difficult to overstate the significance of Medicaid 
in extending health insurance to low- income residents in the state. More than 
400,000 Pennsylvania residents are newly insured as a result of the Medicaid 
expansion.

With this backdrop, our primary goal in this article was to suggest that the 
pre- existing landscape of health inequalities in access to care across different 
regions of the state, coupled with the centralized hybrid structure of health 
governance, will mediate and potentially limit health outcomes among the 
newly insured population. Better and more health insurance will not nec-
essarily lead to better health care or improved health outcomes. Access to 
preventive health services and primary care physicians is not distributed equi-
tably across the state; those newly insured and those who remain uninsured 



The Limits of Medicaid Reform in Pennsylvania  23

will have differential access to health care depending to large degree on where 
they live.

Emergent literature on regionalism and public health, coupled with expe-
riences of innovative regional approaches in states such as Minnesota and 
Massachusetts, suggest that there are tangible ways Pennsylvania (and other 
states) can think regionally about how to best address inequalities in access 
to health. Many academics, research institutions (see, for example, the Insti-
tute for Public Policy and Economic Development), and practitioners advocate 
statewide regionalization for many policy areas beyond health. For example, 
these areas include police, fire, public education, water and wastewater, eco-
nomic development, transportation, and planning. 

Statewide obstacles similar to those found in the Lehigh Valley have frus-
trated these efforts to regionalize while, ironically, the fragmentation of Penn-
sylvania’s local governments further contributes to service delivery challenges 
and fiscal stress. Nonetheless, there has been limited success in regionaliza-
tion that gives us reason for optimism. Since 1971, for instance, 29 regional 
Intermediate Units (IUs), multijurisdictional entities, have provided educa-
tional services and instruction. IUs operate as a statewide network to pro-
vide services to school districts and other educational entities that would not 
be provided if each district were expected to provide its own services; while 
IUs cannot raise their own tax revenues, they do charge fees for service and 
receive state and local funding (Joint State Government Commission 1997). 
There are other examples of successful regionalization in the state; there are 
at least 35 regional police departments across 125 municipalities, and inter-
state and intrastate regional planning commissions are now commonplace 
throughout the Northeast.

As we have shown throughout this article, Pennsylvania’s health system 
requires an overhaul. Pennsylvania continues to rank below national aver-
ages on measures of state population health. The Kaiser Commission recently 
reported that individuals living in rural areas of the state are most likely to 
face the greatest obstacles in accessing health care and in obtaining improved 
health outcomes. A State Health Care Innovation Plan awarded to Pennsyl-
vania in 2013 has begun the development of telemedicine initiatives to help 
address some of these disparities (Kaiser Commission on Medicaid and 
the Uninsured 2016). While a worthy goal, the above suggests that without 
a more regionalized strategic focus on services and service access barriers, 
many low- income Pennsylvanians will continue to lack access to health care 
and improved health, even if newly insured as a result of the ACA Medicaid 
expansion.



24

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4
,6

4
1

1
,5

1
9

4
5

8
3

0
.1

5
%

1
,3

4
7

1
,6

3
4

1
7

.6
%

G
re

en
e

3
4

,0
8

9
4

,4
7

2
1

,1
9

5
2

6
.7

2
%

4
,4

2
9

5
,1

2
2

1
3

.5
%

H
un

ti
ng

do
n

4
0

,6
8

8
4

,5
7

9
1

,1
9

6
2

6
.1

2
%

4
,3

2
2

5
,1

3
1

1
5

.8
%

In
di

an
a

8
3

,2
1

9
1

3
,9

0
3

3
,4

9
6

2
5

.1
5

%
7

,4
1

5
9

,4
3

3
2

1
.4

%

Je
ff

er
so

n
4

4
,1

7
4

5
,5

3
5

1
,5

8
5

2
8

.6
4

%
5

,1
2

8
5

,9
8

4
1

4
.3

%

Ju
ni

at
a

2
4

,3
5

9
2

,6
5

9
9

1
0

3
4

.2
2

%
1

,8
2

8
2

,1
6

5
1

5
.6

%



25

A
P

P
E

N
D

IX
 A

ta
bl

e 
a

.1
. 

P
op

ul
at

io
n,

 u
ni

ns
ur

ed
, 

an
d 

M
ed

ic
ai

d 
e

nr
ol

le
es

 P
re

-  
an

d 
P

os
t-

 M
ed

ic
ai

d 
e

xp
an

si
on

 

to
ta

l 
P

op
ul

at
io

n 
(2

0
1

3
)

P
op

ul
at

io
n 

1
8

–6
4

 u
nd

er
 

1
3

8
 F

P
l 

(2
0

1
3

)

n
um

be
r 

1
8

–6
4

 Y
ea

rs
 

o
ld

 u
nd

er
 

1
3

8
 F

P
l 

u
ni

ns
ur

ed
 

(2
0

1
3

)

P
er

ce
nt

ag
e 

P
op

ul
at

io
n 

1
8

–6
4

 
un

de
r 

1
3

8
 F

P
l 

u
ni

ns
ur

ed

Ju
ne

 2
0

1
4

 
a

du
lt

 
M

ed
ic

ai
d 

e
nr

ol
le

es

Ju
ne

 2
0

1
5

 
a

du
lt

 
M

ed
ic

ai
d 

e
nr

ol
le

es

P
er

ce
nt

ag
e 

c
ha

ng
e 

in
 

a
du

lt
 M

ed
ic

ai
d 

e
nr

ol
le

es
  

Ju
ne

 2
0

1
4

–
Ju

ne
 2

0
1

5

s
ta

te
 t

o
ta

l
1

2
,3

1
1

,6
4

4
1

,3
8

0
,0

8
2

3
9

9
,0

8
6

2
8

.9
2

%
1

,1
2

6
,3

9
6

1
,3

8
3

,6
7

5
1

8
.6

%

A
da

m
s

9
6

,9
2

5
7

,4
9

6
2

,9
2

0
3

8
.9

5
%

5
,0

0
1

6
,7

2
1

2
5

.6
%

A
lle

gh
en

y
1

,1
9

3
,2

8
5

1
3

2
,0

8
5

3
3

,7
8

3
2

5
.5

8
%

1
0

2
,1

7
6

1
2

2
,4

9
6

1
6

.6
%

A
rm

st
ro

ng
6

7
,7

9
4

7
,6

2
7

2
,2

4
0

2
9

.3
7

%
7

,2
4

2
8

,5
7

9
1

5
.6

%

B
ea

ve
r

1
6

7
,2

3
4

1
6

,2
5

7
3

,7
4

1
2

3
.0

1
%

1
5

,7
3

4
1

8
,8

9
8

1
6

.7
%

B
ed

fo
rd

4
8

,6
4

6
5

,3
5

5
1

,6
5

6
3

0
.9

2
%

4
,8

2
3

6
,0

7
4

2
0

.6
%

B
er

ks
3

9
8

,8
9

4
4

3
,6

7
4

1
4

,4
8

2
3

3
.1

6
%

3
4

,5
9

4
4

2
,2

2
2

1
8

.1
%

B
la

ir
1

2
3

,6
0

7
1

5
,2

7
4

3
,6

5
9

2
3

.9
6

%
1

4
,3

4
3

1
7

,3
1

3
1

7
.2

%

B
ra

df
or

d
6

1
,5

5
5

7
,2

6
8

2
,2

4
6

3
0

.9
0

%
5

,7
4

5
6

,7
6

9
1

5
.1

%

B
uc

ks
6

1
7

,1
6

1
3

0
,3

6
6

9
,2

3
4

3
0

.4
1

%
2

8
,2

0
6

3
5

,9
9

2
2

1
.6

%

B
ut

le
r

1
7

9
,4

0
1

1
5

,3
1

1
4

,3
1

0
2

8
.1

5
%

1
0

,8
6

2
1

3
,3

2
4

1
8

.5
%

C
am

br
ia

1
3

4
,4

9
5

1
6

,0
1

8
4

,5
7

9
2

8
.5

9
%

1
5

,1
2

5
1

8
,0

9
5

1
6

.4
%

C
am

er
on

4
,9

2
3

4
9

4
1

1
8

2
3

.8
9

%
6

4
0

7
3

8
1

3
.3

%

C
ar

bo
n

6
4

,0
7

4
6

,8
7

6
1

,9
7

6
2

8
.7

4
%

4
,9

6
0

6
,3

1
2

2
1

.4
%

C
en

tr
e

1
3

7
,1

1
0

2
8

,2
5

4
3

,9
0

4
1

3
.8

2
%

6
,3

4
7

7
,9

8
7

2
0

.5
%

C
he

st
er

4
9

0
,1

9
9

2
9

,6
6

2
1

0
,1

5
0

3
4

.2
2

%
1

6
,9

4
5

2
2

,4
1

5
2

4
.4

%

C
la

ri
on

3
7

,8
5

5
5

,9
5

3
1

,3
4

1
2

2
.5

3
%

3
,8

6
7

4
,5

2
0

1
4

.4
%

C
le

ar
fi

el
d

7
6

,4
6

3
9

,9
5

3
3

,0
5

0
3

0
.6

4
%

9
,6

6
6

1
1

,4
4

8
1

5
.6

%

C
lin

to
n

3
6

,7
6

9
5

,2
1

8
9

8
9

1
8

.9
5

%
3

,9
5

3
4

,6
1

0
1

4
.3

%

C
ol

um
bi

a
6

2
,7

6
3

9
,6

8
5

2
,0

9
0

2
1

.5
8

%
5

,4
1

3
6

,5
6

5
1

7
.5

%

C
ra

w
fo

rd
8

4
,3

2
7

1
1

,5
2

6
3

,5
6

5
3

0
.9

3
%

9
,1

1
7

1
0

,6
8

4
1

4
.7

%

C
um

be
rl

an
d

2
2

3
,2

6
2

1
6

,9
4

1
4

,7
5

1
2

8
.0

4
%

1
0

,9
8

4
1

4
,3

4
9

2
3

.5
%

D
au

ph
in

2
6

2
,8

7
8

2
8

,3
7

0
8

,5
6

0
3

0
.1

7
%

2
2

,0
9

3
2

9
,6

4
8

2
5

.5
%

D
el

aw
ar

e
5

3
8

,1
2

8
4

5
,1

8
0

1
3

,4
2

1
2

9
.7

1
%

4
2

,2
1

6
4

9
,1

2
7

1
4

.1
%

E
lk

3
1

,4
1

1
2

,5
2

8
5

1
7

2
0

.4
5

%
2

,7
2

8
3

,1
3

3
1

2
.9

%

E
ri

e
2

6
8

,0
4

4
3

7
,0

0
3

9
,1

6
1

2
4

.7
6

%
3

1
,3

8
7

3
8

,4
6

9
1

8
.4

%

Fa
ye

tt
e

1
3

2
,1

3
8

2
0

,2
8

6
6

,1
0

1
3

0
.0

7
%

2
0

,1
9

9
2

3
,7

8
5

1
5

.1
%

Fo
re

st
4

,8
0

3
6

9
0

2
2

5
3

2
.6

1
%

5
7

4
7

1
5

1
9

.7
%

Fr
an

kl
in

1
4

7
,6

4
0

1
3

,3
5

4
5

,3
2

0
3

9
.8

4
%

9
,3

3
3

1
2

,3
9

6
2

4
.7

%

Fu
lt

on
1

4
,6

4
1

1
,5

1
9

4
5

8
3

0
.1

5
%

1
,3

4
7

1
,6

3
4

1
7

.6
%

G
re

en
e

3
4

,0
8

9
4

,4
7

2
1

,1
9

5
2

6
.7

2
%

4
,4

2
9

5
,1

2
2

1
3

.5
%

H
un

ti
ng

do
n

4
0

,6
8

8
4

,5
7

9
1

,1
9

6
2

6
.1

2
%

4
,3

2
2

5
,1

3
1

1
5

.8
%

In
di

an
a

8
3

,2
1

9
1

3
,9

0
3

3
,4

9
6

2
5

.1
5

%
7

,4
1

5
9

,4
3

3
2

1
.4

%

Je
ff

er
so

n
4

4
,1

7
4

5
,5

3
5

1
,5

8
5

2
8

.6
4

%
5

,1
2

8
5

,9
8

4
1

4
.3

%

Ju
ni

at
a

2
4

,3
5

9
2

,6
5

9
9

1
0

3
4

.2
2

%
1

,8
2

8
2

,1
6

5
1

5
.6

%



26

ta
bl

e 
a

.1
 (
co
nt
in
ue
d)

 

to
ta

l 
P

op
ul

at
io

n 
(2

0
1

3
)

P
op

ul
at

io
n 

1
8

–6
4

 u
nd

er
 

1
3

8
 F

P
l 

(2
0

1
3

)

n
um

be
r 

1
8

–6
4

 Y
ea

rs
 

o
ld

 u
nd

er
 

1
3

8
 F

P
l 

u
ni

ns
ur

ed
 

(2
0

1
3

)

P
er

ce
nt

ag
e 

P
op

ul
at

io
n 

1
8

–6
4

 
un

de
r 

1
3

8
 F

P
l 

u
ni

ns
ur

ed

Ju
ne

 2
0

1
4

 
a

du
lt

 
M

ed
ic

ai
d 

e
nr

ol
le

es

Ju
ne

 2
0

1
5

 
a

du
lt

 
M

ed
ic

ai
d 

e
nr

ol
le

es

P
er

ce
nt

ag
e 

c
ha

ng
e 

in
 

a
du

lt
 M

ed
ic

ai
d 

e
nr

ol
le

es
  

Ju
ne

 2
0

1
4

–
Ju

ne
 2

0
1

5

La
ck

aw
an

na
2

0
6

,3
1

8
2

3
,2

3
0

6
,4

5
9

2
7

.8
0

%
2

1
,4

5
0

2
6

,5
3

2
1

9
.2

%

La
nc

as
te

r
5

0
8

,3
9

7
4

5
,9

3
5

1
4

,7
5

6
3

2
.1

2
%

3
4

,4
5

9
4

2
,8

4
7

1
9

.6
%

La
w

re
nc

e
8

7
,9

0
4

1
0

,0
4

0
2

,9
7

3
2

9
.6

1
%

9
,6

4
7

1
1

,7
0

3
1

7
.6

%

Le
ba

no
n

1
3

0
,6

2
0

1
1

,1
3

7
3

,4
6

1
3

1
.0

8
%

9
,5

2
9

1
2

,3
9

4
2

3
.1

%

Le
hi

gh
3

4
2

,3
0

1
3

7
,3

4
2

1
3

,1
6

3
3

5
.2

5
%

3
0

,7
9

2
3

9
,3

3
7

2
1

.7
%

Lu
ze

rn
e

3
0

9
,2

0
0

3
7

,7
1

9
1

1
,6

4
6

3
0

.8
8

%
3

2
,5

3
1

4
0

,1
9

7
1

9
.1

%

Ly
co

m
in

g
1

1
1

,1
2

9
1

3
,6

1
9

3
,7

8
2

2
7

.7
7

%
1

1
,1

2
1

1
3

,5
8

6
1

8
.1

%

M
cK

ea
n

4
0

,0
3

9
5

,6
2

0
1

,4
1

4
2

5
.1

6
%

4
,9

4
7

5
,9

6
8

1
7

.1
%

M
er

ce
r

1
0

8
,8

5
4

1
2

,6
6

1
3

,3
7

6
2

6
.6

6
%

1
2

,7
5

4
1

4
,7

4
5

1
3

.5
%

M
if

fl
in

4
6

,0
6

9
6

,1
8

2
2

,1
3

5
3

4
.5

4
%

5
,2

5
8

6
,0

7
6

1
3

.5
%

M
on

ro
e

1
,6

5
2

,2
0

2
1

8
,3

4
6

6
,0

5
8

3
3

.0
2

%
1

3
,3

6
7

1
6

,9
1

6
2

1
.0

%

M
on

tg
om

er
y

7
8

4
,2

0
2

4
2

,4
6

4
1

2
,9

6
8

3
0

.5
4

%
3

7
,1

1
2

4
9

,4
7

1
2

5
.0

%

M
on

to
ur

1
7

,7
5

7
1

,5
9

1
5

3
5

3
3

.6
3

%
1

,5
3

0
1

,7
3

1
1

1
.6

%

N
or

th
am

pt
on

2
8

7
,1

1
3

2
3

,6
9

3
6

,5
7

4
2

7
.7

5
%

1
9

,8
0

3
2

6
,0

3
4

2
3

.9
%

N
or

th
um

be
rl

an
d

8
9

,8
5

2
1

1
,1

6
3

3
,9

1
1

3
5

.0
4

%
9

,5
5

2
1

1
,6

8
4

1
8

.2
%

P
er

ry
4

5
,0

6
1

3
,5

7
8

1
,2

4
3

3
4

.7
4

%
2

,7
3

9
3

,4
3

1
2

0
.2

%

P
hi

la
de

lp
hi

a
1

,4
9

3
,7

4
5

3
1

6
,9

5
2

8
8

,6
9

6
2

7
.9

8
%

2
7

1
,4

8
6

3
2

6
,4

7
3

1
6

.8
%

P
ik

e
5

6
,4

1
4

5
,0

0
0

1
,8

5
1

3
7

.0
2

%
3

,3
9

9
4

,7
5

0
2

8
.4

%

P
ot

te
r

1
7

,1
7

0
2

,1
5

8
6

8
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28 Michele Moser Deegan anD a. lanethea Mathews- schultz

NOTES

1. The ACA extends Medicaid coverage to individuals living at 133% of the FPL, but 
requires states to apply a 5% income disregard in determining eligibility, effectively bring-
ing minimum eligibility requirements to 138% of the federal poverty level.

2. In response to mandated Medicaid expansion and to the “individual Mandate” pro-
visions of the ACA requiring individuals to obtain health insurance or face a tax penalty, 
26 states and the National Association of Independent Businesses sued the federal govern-
ment. The states were Alabama, Alaska, Arizona, Colorado, Florida, Georgia, Idaho, Indi-
ana, Iowa, Kansas, Louisiana, Maine, Michigan, Mississippi, Nebraska, Nevada, North 
Dakota, Pennsylvania, Ohio, South Carolina, South Dakota, Texas, Utah, Washington, 
Wisconsin, and Wyoming.

3. Others include Arkansas, Maine, Oklahoma, Tennessee, and Wyoming. Of these, 
only Arkansas is reforming Medicaid and it is doing so through a Section 1115 Waiver, 
rather than the ACA expansion. Pennsylvania is the only mixed or hybrid state to have 
adopted the ACA Medicaid expansion.

4. A handful of additional states pursued similar state- run privatized alternatives for 
expanding Medicaid, including Arkansas, Iowa, Michigan, and Tennessee.

5. These individuals are referred to as PCO beneficiaries because they receive care 
through private managed plans. Eligibility under Corbett’s Private Coverage Program 
was limited to individuals ages 21–64 with incomes up to 133% of the federal poverty 
level, including childless adults and those with incomes greater than 33% FPL, which was 
previously the income cap for Medicaid in Pennsylvania. Existing Medicaid recipients 
were funneled into one of two new managed plans: a high- risk pool enrolling pregnant 
women, SSI beneficiaries, and those eligible for Medicare and Medicaid; and a low- risk 
pool offering more limited medical services. Newly eligible adults not determined to be 
“medically frail” were enrolled in the Private Coverage option.

6. The CMS project stipulated that cost sharing and premium contributions could not 
exceed 5% of family income.

7. Marilyn Tavenner, Secretary, Federal Department of Health and Human Services to 
Beverly Mackereth, Secretary of the Pennsylvania Department of Public Welfare, August 
28, 2014.

8. Prior to the ACA, states were already required to provide coverage at higher levels 
to children and pregnant women.

9. Some 19-  and 20- year- old adults without children with incomes up to 33% FPL 
previously were eligible for coverage.

10. Press Release 2015.
11. One limitation is that for the purposes of Medicaid eligibility in the state of Penn-

sylvania, adults are considered individuals ages 21–64. The Census data on poverty and 
the uninsured, however, defines adults as those ages 18–64.

12. We do not estimate it here, but it is important not to underappreciate the effects of 
Obamacare and Medicaid expansion on individuals previously eligible for but nonetheless 
un- enrolled in Medicaid.

13. Prior to implementation of the ACA, county and municipal health departments 
could provide primary care services not available through state district offices, such as 
immunizations, mammograms, and dental services.



The Limits of Medicaid Reform in Pennsylvania  29

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sylvania.” Newsworks, February 5. Available at www.newsworks.org/index.php/
local/healthscience/50558-corbett-rejects-obamacare-medicaid-expansion-for 
-pennsylvania. Accessed June 24, 2016.

Brecher, Charles, and Shanna Rose. “Medicaid’s Next Metamorphosis.” Public Adminis-
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Central Massachusetts Regional Public Health Alliance. 2014. Greater Worcester Com-
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Hays, Justeen, Naxmim Bhuiya, Maeve Conlin, Michael Coughlin, and Geoffrey Wilkin-
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Hyde, Justeen, and Alison Tovar. 2006. “Strengthening Local Public Health in Massachu-
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Jacobs, L. R., and T. Callaghan. 2013. “Why States Expand Medicaid: Party, Resources, 
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Joint State Government Commission. 1997. “Intermediate Units in Pennsylvania: The Role 
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Kaiser Commission on Medicaid and the Uninsured. 2012. “Where Are States Today? 
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———. 2016. “The Pennsylvania Health Care Landscape.” Available at kff.org/health 
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Kenny, Genevieve, Lisa Dubay, Stephen Zuckerman, and Michael Huntress. 2012. “Opting 
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Kirby, J. B., and T. Kaneda. 2005. “Neighborhood Socioeconomic Disadvantage and 
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http://www.newsworks.org/index.php/local/healthscience/50558-corbett-rejects-obamacare-medicaid-expansion-for-pennsylvania
http://www.newsworks.org/index.php/local/healthscience/50558-corbett-rejects-obamacare-medicaid-expansion-for-pennsylvania
http://www.newsworks.org/index.php/local/healthscience/50558-corbett-rejects-obamacare-medicaid-expansion-for-pennsylvania
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30 Michele Moser Deegan anD a. lanethea Mathews- schultz

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The Limits of Medicaid Reform in Pennsylvania  31

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Michele Moser Deegan, PhD, is an associate professor and the chair of the Political Sci-
ence Department at Muhlenberg College. She is also the founding director of the Lehigh 
Valley Research Consortium. Her research and publications focus on issues of inequality 
at the local level, particularly in the areas of education and health policy. Her publica-
tions include articles in the Journal of Urban Affairs, Public Administration Review, and 
Educational Evaluation and Policy Analysis and multiple research studies of the Lehigh 
Valley region of Pennsylvania.

a. lanethea Mathews-s chultz, PhD, is an associate professor of political science at 
Muhlenberg College, where she teaches classes on American politics, gender and public 
policy, citizenship, and political institutions. As an independent researcher affiliated with 
the Lehigh Valley Research Consortium, she has conducted several regional studies of 
community health, focusing on access and equity issues in health and well-b eing. Her 
recent work has been published in Political Research Quarterly and Progress in Community 
Health Partnerships: Research, Education, and Action.

http://www.pennlive.com/midstate/index.ssf/2014/08/pennsylvania_corbett_obamacare.html
http://www.pennlive.com/midstate/index.ssf/2014/08/pennsylvania_corbett_obamacare.html

	Structure Bookmarks
	The Limits of Medicaid Reform in Pennsylvania
	Seeking Regional Solutions to Health Challenges  in Pennsylvania




