Amid the deadliest pandemic to afflict America in a century and surging unemployment, Medicaid expansion is having a moment. In recent months, two deeply conservative states— Oklahoma and Missouri — voted to expand Medicaid despite opposition from Republican state leaders.
With the majority of voters in both political parties recognizing the value of Medicaid expansion, now is the time for the remaining 12 states to take this action.
Medicaid is now more critical than ever
State and federal governments jointly fund health insurance for low-income parents and children through Medicaid. The Affordable Care Act (ACA) allows states to expand Medicaid to all adults earning less than 138 percent of the federal poverty level (FPL) or just under $30,000/year for a family of three.
While 38 states and DC have expanded Medicaid, the remaining 12 states that have not done so are mainly Republican-governed and in the South. As a result, this latter group of states has a "coverage gap." Residents may earn too much to qualify for Medicaid (in some places, "too much" can be as little as $4,000 a year for a family of three), but below the threshold to qualify for subsidies within state health insurance marketplaces (100 percent FPL).
Worse yet, in these same states, childless adults cannot get Medicaid at all, regardless of salary. With COVID-19 shuttering American businesses, 27 million Americans have lost their employer-based health insurance, leaving them vulnerable to this coverage gap.
Medicaid expansion stabilizes the health care system
With COVID-19 cases rising, parts of the country are experiencing shortages of hospital beds and medical staff, and the United States is suffering some of the worst COVID-19 death rates globally. The stabilization of the American health care system is paramount. Expanding Medicaid accomplishes this by significantly decreasing uncompensated care, allowing hospitals and clinics to stay financially viable. This problem is especially urgent for America's rural hospitals, of which 106 have closed since 2013. Seventy-two percent of these closures were in states that did not expand Medicaid.
Medicaid expansion saves lives
Sixty percent of Americans have a chronic disease (such as diabetes, asthma, hypertension, kidney disease, and heart disease), which also increases one's risk of complications from COVID-19. Yet one in seven Americans plans to avoid medical care for COVID-19 due to cost concerns — undermining our ability to track and treat the virus. This correlates with broader trends showing more Americans are delaying care due to cost and rising medical debt.
Medicaid expansion improves Americans' health through the provision of affordable health care access. A study found that from 2014 to 2017, an estimated 19,200 lives were saved due to Medicaid expansion. Meanwhile, 15,600 premature deaths occurred in non-expansion states over the same period.
Medicaid expansion improves health disparities
COVID-19 infections and deaths have disproportionately occurred within minority communities due to higher rates of exposure (e.g. through employment as essential workers, crowded multi-generational housing) and higher rates of chronic disease due to centuries of systemic inequities in the social determinants of health. If Medicaid expanded in the remaining states, most of the beneficiaries would be people of color (23 percent African American, 29 percent Hispanic), helping narrow disparities in health care access.
Medicaid expansion steadies state budgets
States face an extreme financial toll by not expanding Medicaid, which mounts daily. Non-expansion states have lost out on billions in federal funding. Under expanded Medicaid, the federal government covers 90 percent of the expense, with states paying the remaining 10 percent. While opponents fear rising costs, research shows that Medicaid expansion has not led to skyrocketing Medicaid costs in any expansion state. Instead, expansion states have saved money by directing federal Medicaid funds towards previously state-funded health expenses, such as correctional health care. Multiple studies show that federal Medicaid dollars can create thousands of new jobs and millions of dollars in local economic activity. Given the current dire condition of state budgets and local economies, Medicaid expansion offers a much-needed economic stimulus.
While undoubtedly a crisis, COVID-19 presents an opportunity to rethink the way we deliver health care in the United States. As the November elections draw near, residents in the 12 remaining states must take action. Four states (Florida, Mississippi, South Dakota, Wyoming) allow their citizens to vote to expand Medicaid via ballot referendum; efforts are already underway. Voters in the other states (Alabama, Georgia, Kansas, North Carolina, South Carolina, Tennessee, Texas, and Wisconsin) should use the power of the ballot box this November to vote for candidates supportive of Medicaid expansion. In doing so, these voters can improve health care for all.
Marisa K. Dowling, M.D., MPP, is a health policy fellow at the George Washington University Department of Emergency Medicine. Janice Blanchard M.D. Ph.D. is a Professor at the George Washington University Department of Emergency Medicine. Jennifer Lee, M.D., is a Clinical Associate Professor at the George Washington University Department of Emergency Medicine and the former Medicaid Director for the Commonwealth of Virginia.