The Impact of the Coverage Gap in States not Expanding Medicaid by Race and Ethnicity

Kaiser Family Foundation, December 17, 2013

Medicaid eligibility for adults is very limited. Many states limit Medicaid eligibility for parents to below poverty, and adults without dependent children have historically been excluded from the program. The ACA’s Medicaid expansion to adults with incomes at or below 138% FPL would significantly increase eligibility for parents in many states and end the exclusion of adults without dependent children from the program. The expansion was intended to occur nationwide as of January 2014 and serve as the base of coverage for low-income individuals, with premium tax credits available to moderate-income individuals above Medicaid limits to purchase Marketplace coverage. However, as a result of the Supreme Court decision on the ACA, implementation of the Medicaid expansion is now effectively a state choice. As of December 11, 2013, 26 states, including DC, are moving forward with the Medicaid expansion in 2014, while 25 states are not moving forward at this time.

In states that do not expand Medicaid, nearly five million poor uninsured adults will fall into a “coverage gap.” These individuals would have been eligible for Medicaid if their state had chosen to expand coverage. In the absence of the expansion, they remain ineligible for Medicaid and do not earn enough to qualify for premium tax credits to purchase Marketplace coverage, which begin at 100% FPL. Most of these individuals have very limited coverage options and are likely to remain uninsured.

These continued coverage gaps will likely lead to widening racial and ethnic as well as geographic disparities in coverage and access.

Table 1: Nonelderly Poor Uninsured Adults in the Coverage Gap in States Not Expanding Medicaid by Race/Ethnicity

Total, United States

4,832,000  –  All races/Ethnicities
2,248,000  –  White
1,327,000  –  Black
992,000  –  Hispanic
265,000  –  Other
2,584,000  –  People of Color…

Since it was decided to reject reform that would have been truly universal, you would think that at least we would be covering the most vulnerable segments of our population. But no, half of our states rejected federal funding for Medicaid expansion, leaving almost 5 million otherwise qualified individuals out of the Medicaid program, even though their incomes ironically are too low to qualify them for subsidies to purchase plans in the state insurance exchanges.

Over half of these people left out are people of color, resulting in a widening of the unjust disparities in care already plaguing our nation.

What a terrible way to start the first year of what is essentially the full implementation of the Affordable Care Act. It seems pretty obvious what our New Year’s resolution should be: Let’s bring health care to everyone through an improved and expanded Medicare for all.