A new brief from the Kaiser Family Foundation (KFF) examines how state decisions to forego the Affordable Care Act’s (ACA) Medicaid expansion have impacted Americans’ access to coverage.
The ACA expanded Medicaid eligibility to adults with incomes at or below 138% of the federal poverty level (FPL) ($17,236 for an individual in 2019). Importantly, this expansion was intended to create a pathway to coverage for low-income adults across the country and was designed as a complement to the health law’s Marketplace subsidies, which help people with moderate incomes purchase coverage.
However, a 2012 Supreme Court ruling made the Medicaid expansion optional for states and, to date, 14 states have not yet expanded their programs. The consequences of this inaction are significant. Medicaid eligibility for adults in non-expansion states is extremely low: the median income limit is just 40% of the FPL, or $8,532 for a family of three in 2019. As a result, 2.3 million low-income Americans are uninsured because their income is too high to qualify for their state’s Medicaid program, but too low to qualify for Marketplace subsidies, and they cannot afford coverage on their own.
KFF estimates that if these holdout states were to adopt the expansion, more than 4.8 million Americans would gain access to Medicaid. This includes those in the Medicaid-Marketplace “coverage gap,” as well as another 2.1 million uninsured adults with incomes between 100 and 138% of the FPL. Though many in this cohort are currently eligible for Marketplace subsidies, Medicaid would likely provide them with more comprehensive benefits at a lower cost.
The ACA’s Medicaid expansion works to provide an affordable coverage option for people with limited incomes who lack access to other insurance. In the 37 states that have expanded Medicaid, the uninsured rate has dropped significantly, while in non-expansion states, millions remain without affordable coverage. These disparities are only widening. From 2017 to 2018, non-expansion states saw a significant increase in their uninsured rate, while expansion states did not.
The positive effects of the ACA’s Medicaid expansion are well documented. Overall, these findings consistently link expanded programs with improvements in access and coverage for individuals and with economic benefits for states and providers. Importantly, there is no deadline for states to expand Medicaid eligibility. Medicare Rights continues to urge all states to thoughtfully implement this option in ways that strengthen enrollee health and financial security.