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An Urgent Opportunity to Close the Medicaid Gap

Ten states have yet to expand eligibility under the Affordable Care Act. Doing so would save lives, improve financial well-being, save states money and support regional economies.

Medicaid sign
Ten years ago, one of the Affordable Care Act’s most impactful coverage provisions, Medicaid expansion, went into effect, resulting in affordable health-care coverage and life-changing improvements for millions of low-income Americans. Unfortunately, despite Medicaid expansion’s obvious benefits, there are still 10 states that haven’t expanded eligibility.

Against the backdrop of changing political dynamics and the “unwinding” of the broader coverage requirements instituted during the COVID-19 pandemic, policymakers in those states have an urgent opportunity to close the coverage gap. Full adoption of expanded Medicaid eligibility by the remaining states would provide coverage to 2.3 million people, advance access to care, improve health outcomes, support financial security and reduce health disparities.

Today, it’s easy to see how Medicaid expansion transformed the U.S. health-care landscape. By extending Medicaid eligibility to a broader population, including childless adults and family caregivers, more than 18 million Americans have coverage thanks to the Affordable Care Act. States that have expanded Medicaid have dramatically decreased their uninsured rates and helped improve coverage for young adults and Black and Hispanic people.

Medicaid expansion means more than coverage gains — it reflects lives changed and even saved. The millions of people now covered by Medicaid benefit from significant financial protections like limits on out-of-pocket expenses. Research has also found Medicaid expansion improves financial well-being and reduces medical debt.

People in expansion states are now accessing preventive care and treatment for chronic conditions and mental health services that they otherwise would not have been able to reach. This is important, as a lack of affordable care access can have deadly consequences — a reality that the Pernell family from North Carolina knows all too well. For more than 30 years, Brenda Pernell followed her calling to nurture young people. “Miss Brenda,” as she was known to her students, was an early childhood educator who fell within the coverage gap, making too much to be eligible for traditional Medicaid but not enough to qualify for ACA marketplace subsidies.

Without health insurance, Brenda was unable to afford treatment for her heart condition and high blood pressure, instead relying on home remedies. In April 2019, the dedicated educator and mother of three died from a stroke at the age of 52. Last year, North Carolina became the 40th state to adopt Medicaid expansion, granting access to life-saving coverage for 600,000 residents and helping to ensure that other families are less likely to experience the heartbreak the Pernell family did.

For state governments, Medicaid expansion also makes economic sense. By reducing the number of uninsured residents, expanding Medicaid decreases uncompensated-care costs, helping to reduce the financial burden on state budgets as well as the health-care system generally — and in particular for rural hospitals.

Despite policymakers’ initial concerns about increased costs and state spending, state expenditures related to Medicaid expansion are nearly completely offset by federal funding, especially now that enhanced federal financing is available. By expanding Medicaid, states can make a dual investment in health and in their regional economies. It’s encouraging that policymakers in some of the remaining states are starting to recognize this, but their attempts to attach conditions such as work requirements may blunt any new expansion’s full impact.

As the United States celebrates 10 years of Medicaid expansion, the evidence of its benefits is clear and well proven. The time is now to build on the nation’s tremendous success: The remaining 10 states should expand Medicaid and help make health care accessible for all.

Natasha Murphy is the director of health policy at the Center for American Progress.

Governing’s opinion columns reflect the views of their authors and not necessarily those of Governing’s editors or management.
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