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A Race to the Bottom for Medicaid

Some states' alternative approaches to expanding the program are compromising access to health care for the neediest.

Thanks to the Affordable Care Act, nearly 9 million more people have enrolled in Medicaid and the Children's Health Insurance Program. Combined with the gains made through marketplace coverage for people with higher incomes, experts forecast that the number of Americans without health insurance will drop from 45 million in 2012 to as few as 23 million by 2023. Amid all that good news, however, there are troubling efforts that could deny some of the neediest among us the health care they need.

Particularly for the poor and low-income, the ACA's expansion of health coverage is a remarkable achievement, More than 4 in 10 poor adults -- for an individual, that means earning less than $11,770 a year -- were uninsured in 2012. Seventy-five percent of all non-elderly uninsured had annual incomes of no more than $29,425 (250 percent of the federal poverty level).

Taking advantage of the billions in federal dollars to expand Medicaid under the ACA should be an easy choice for states. Yet a handful of governors are brokering deals for alternative forms of expansion by seeking waivers from the federal Centers for Medicare and Medicaid Services (CMS). The waivers essentially allow a state to expand coverage for low-income individuals without expanding traditional Medicaid -- a way to avoid being perceived as "supporting Obamacare."

If it takes a waiver to ensure that low-income women and men get the care they need, that's fine. But so far, these waivers promote a race to the bottom. Just last week, CMS approved a request by Indiana's Republican governor, Mike Pence, for an alternative expansion that not only charges premiums of between $3 and $25 a month to individuals with incomes barely above $11,770 a year but strips them of coverage and locks them out of benefits for six months if they don't pay their premiums. The poorest of Hoosiers won't be required to pay premiums, but if they choose not to they will get fewer benefits and will be charged co-pays for medical care.

Expanding coverage is meaningless if it compromises the ability of low-income populations to access the care they need. We also cannot assume that the historic expansion of coverage under the ACA means that everyone will be covered. Even under the best circumstances, millions will remain uninsured or underinsured and continue to need and seek publicly funded health services.

That's just part of why the safety net is vital -- to catch those who fall through the coverage gaps. And since public- and private-sector health care providers are in scarce supply, safety-net providers also help care for those with coverage.

Everyone deserves a basic standard of care, regardless of economic status. While states work to expand insurance coverage, it is imperative that such coverage not come at the expense of creating a two-tiered system in which low-income individuals get less access to care. In making its decisions to grant waivers, the Obama administration must recognize that to fulfill the promise of the ACA we need to regain our footing.

Clare Coleman is president and chief executive officer of the National Family Planning & Reproductive Health Association.
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