After Eight Years It’s Past Time to Close the Medicaid Coverage Gap

Eight years after most states began covering low-income adults in their Medicaid programs as called for in the Affordable Care Act (ACA), more than 2 million people are still waiting for health coverage because 12 states still refuse to adopt the expansion despite extensive evidence of the expansion’s health and economic benefits and despite financial incentives for states that newly expand. The House passed Build Back Better legislation in November that would finally provide coverage to adults with low incomes in these holdout states. Now it’s the Senate’s turn to deliver on the promise of the ACA and provide immediate access to coverage for over 2 million Americans.

Those missing out on coverage are diverse — some 60 percent are people of color and those who fall into the so-called “coverage gap” come from both urban and rural communities. Many of the states that have refused to adopt the expansion are Southern states that have high uninsured rates and a long history of policy decisions that restrict access to health coverage, often driven by racist views of who deserves coverage.

In the wake of a pandemic and economic crisis that has hit Black and Latino communities especially hard — and growing recognition of how racism and other forms of discrimination affect people’s health, employment, and education — many policymakers have called for policies to narrow racial disparities and promote equity. Providing coverage to people affected by their states’ refusal to expand Medicaid is one way policymakers can back up their rhetoric.

People in the coverage gap include parents, people in low-paid jobs often in front-line industries, caregivers, veterans, people with disabilities, and other adults with incomes below $12,880 a year for a single person and $21,960 for a family of three. Some 2.2 million uninsured people lacked a pathway to coverage in 2019, but even more are affected over time because people move in and out of the coverage gap as their income changes or they lose coverage.

Under the House-passed Build Back Better bill, this group of people could enroll in the health care marketplace for zero-premium plans with very low deductibles and other cost-sharing charges from January 1, 2022, through 2025.

Closing the coverage gap would help address the current crisis in Black maternal health, expand access to mental health care and substance use disorder treatment, and protect more people from medical debt. (The average amount of medical debt is much higher in the South, where most people in the coverage gap live.)

Closing the coverage gap can also help stabilize rural and community health providers, which have a diverse group of patients and serve communities with significant gaps in health care access. These providers continue to face overwhelming challenges in responding to the pandemic.

Finally, closing the coverage gap would bring more stability to people’s lives, which is especially critical as the pandemic has exacerbated mental health and substance use disorder conditions and financial hardship. The many people it would help include:

• Deneen Robinson of Dallas, Texas, who became uninsured last year when her position at a nonprofit organization was eliminated and who needs treatment for a worsening endocrine condition.
• Michael Priesmeyer of Parsons, Kansas, who has multiple disabilities but lost his Children’s Health Insurance Program coverage when he turned 19. Other family members are insured but they can’t afford the medications and care he needs.
• Amy Bielawski of Tucker, Georgia, a 56-year-old small business owner who has had to delay needed surgery and faces anxiety due to her inability to address her health issues as she gets older.
• Christine Burk of Fayetteville, North Carolina, who couldn’t afford needed counseling after being held up at gunpoint. Her only option for her other health care needs is the emergency room, and a recent visit left her with a large bill for her care.
• Jabriel Muhammad of Fayette, Mississippi, a 40-year-old self-employed carpenter and plumber who is paying off a $1,400 hospital bill after receiving an MRI to diagnose a breathing problem.