Closing the Medicaid Coverage Gap is a Health, Economic, and Moral Imperative

This is an ongoing injustice that must be corrected as soon as possible. Fortunately, Congress has an incredible opportunity to do so right now. The House and Senate have passed the framework of a $3.5 trillion budget resolution for Fiscal Year 2022 that has the potential to dramatically reshape the health care landscape in the United States. As Congress finalizes this framework over the coming weeks, a permanent closure of the Medicaid coverage gap must be at the top of the priority list.

The Past

Medicaid was created in 1965 and is jointly funded and administered by the federal government in all 50 states. At its inception, the program provided health coverage to those who qualified for other forms of government cash assistance. Over the years, the program expanded to serve not only families with low incomes, but also pregnant women, people with disabilities, and those who require long-term care.

Under the original Affordable Care Act enacted in 2010, states were required to expand their Medicaid programs to any residents whose income levels were up to 138 percent of the federal poverty line (in 2021, the federal poverty threshold is $26,500 for a family of four); substantial federal funding was included in the law to cover the vast majority (currently 90 percent) of states’ expansion costs. However, a 2012 Supreme Court decision eliminated the mandate and instead left the expansion decision up to each state. States have had the option to do so since 2014.

The Present

An overwhelming body of research shows that Medicaid expansion under the ACA has been an unqualified success. In states that have taken this step, the rates of the uninsured have dropped significantly, particularly among communities of color and those with low incomes; participants have experienced improved health outcomes, including reduced incidence of premature deaths and fewer cases of maternal mortality; and state economies have seen lower health care costs along with increased economic activity due to healthier populations. And thanks to subsequent legislation, there are additional federal funding incentives for states to take this step.

There is no health or economic rationale, then, for the holdout states’ ongoing refusal to expand. Ultimately, it is a question of whose lives we value in our country and whose we don’t, and right now, policymakers in 12 states have decided that the lives of more than two million people don’t have value. It should not come as a surprise, then, that the populations most affected by the holdout states’ refusal to expand are the same ones that have been disproportionately affected by COVID-19 and the structural racism and discrimination that have been baked into our country for centuries. People of color represent more than 60 percent of the coverage gap population, and relative to their overall percentage of the U.S. population, both Blacks and Hispanics are disproportionately counted among this group: Black people in America, for instance, represent 14 percent of the U.S. population but 28 percent of the coverage gap population. And while more than 60 percent of those in the coverage gap are employed, many are in low-wage jobs that are more likely to not offer health insurance. For the working poor, there is often no other health care coverage available than Medicaid, and that option is being foreclosed on them in too many places.

As a Black woman and a Black mother, I am also particularly attuned to our nation’s abysmal rates of maternal mortality, and Medicaid’s potential to change the trajectory for Black families. Per the Center on Budget and Policy Priorities, more than 800,000 people in the coverage gap are women of childbearing age. The United States has the highest maternal mortality rate of any developed country in the world, with Black women at the greatest risk for dying before, during, or after the birth of a child. Expanding Medicaid coverage would make it easier and safer for Black women to have healthy pregnancies that result in healthy deliveries and healthy children.

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