The expansion of Medicaid—an option created by the Affordable Care Act (ACA) that allows states to use federal funds to extend Medicaid coverage to a broader group of people—has been a lifeline for millions of lower-income individuals and families. Traditional Medicaid eligibility is largely limited to low-income pregnant people; children and some parents; certain seniors; and some disabled people. In the absence of state initiatives to expand eligibility, childless adults are unable to enroll in Medicaid coverage no matter how low their incomes.
The ACA allows states to offer Medicaid coverage to all adults with incomes up to 138 percent of the federal poverty level (FPL). In states that adopted the ACA’s Medicaid expansion, the federal government covers nearly all the costs. Federal funding initially paid for the entire cost of expanded coverage and eventually phased down to cover 90 percent of enrollees newly eligible under expansion. Despite the relatively small cost to states—or even net savings to many states’ budgets— and the evidence that expansion improves coverage, health, and other outcomes, 12 states have refused to expand Medicaid to their low-income residents.
About 2.2 million adults fall into the coverage gap in the 11 states where their incomes are too low to qualify for subsidized coverage through the ACA marketplaces—which is available starting at 100 percent of the FPL—yet do not meet their state’s criteria for Medicaid eligibility.* These people have no option for affordable comprehensive health coverage solely because their states have not chosen to expand Medicaid eligibility. Those in the coverage gap represent a diverse population: 49 percent are female; 62 percent are in the labor force; and 30 percent are parents with children at home. The lack of Medicaid expansion disproportionately harms Black, Latino, and other communities of color who are the more likely than white Americans to be uninsured.
Congressional leaders have a critical opportunity to include a comprehensive, permanent solution to closing the coverage gap during the budget reconciliation process. Closing the Medicaid coverage gap is a crucial opportunity to address racial disparities in health coverage and health inequities.
New estimates from the Center for American Progress show how many people in each Congressional district in nonexpansion states are stuck in the Medicaid coverage gap. (see Table 1) On average, about 18,000 uninsured adults are in the coverage gap in each of the 123 districts in the 11 nonexpansion states. For example, in Texas’s 15th Congressional District, 43,100 people fall into the coverage gap, while 25,900 people are in the gap in the 8th District of Georgia.
Table 1
Medicaid expansion is a tried and true initiative that can improves access to health care for some of the most underserved adults in the United States at very little or no cost to state budgets. If congressional leaders are truly committed to improving the well-being of the American people across the country—especially as the United States begins to recover from the pandemic’s damage to health and the economy—they must ensure Medicaid coverage is not dependent on what state a person lives in in the next legislative package.
Nicole Rapfogel is a research assistant for Health Policy at the Center for American Progress. Emily Gee is a senior fellow and the senior economist for Health Policy at the Center.
*Authors’ note: While Wisconsin has not fully expanded Medicaid under the ACA, it has no gap because Medicaid eligibility extends to 100 percent of the FPL.
Methodology
The starting point for the authors’ estimate of people in the Medicaid coverage gap by congressional district is the state-level estimates from the Center on Budget and Policy Priorities (CBPP). According to CBPP, about 2.2 million uninsured nonelderly adults in 11 states fall into the coverage gap.
To allocate CBPP’s state estimates across congressional districts, the authors assumed that the distribution of people in the coverage gap was proportional to each district’s share of uninsured people with incomes under 100 percent of the FPL in a given state. The 2019 American Community Survey from the U.S. Census Bureau provides estimates of the uninsured by income and by district for the 116th Congress, whose district boundaries are identical to those of the current 117th Congress for all states except North Carolina.
For North Carolina, where the district boundaries were redrawn before the 2020 election, the authors created district-level approximations of the uninsured based on county-level estimates of the uninsured with incomes below 100 percent of the FPL from the U.S. Department of Health and Human Services. The authors assigned counties to districts using redistricting information from North Carolina; counties that spanned multiple districts were split according to population share.
The district estimates may not precisely sum to CBPP’s state totals or the nationwide total for nonexpansion states due to rounding. Representative names are from the list available online from the Office of the Clerk of the U.S. House of Representatives.
One limitation of the authors’ method for allocation of nonelderly adults in the coverage gap is that the estimates of uninsured with incomes below 100 percent of the FPL include uninsured children and elderly adults; people already eligible for yet not enrolled in Medicaid; and, in the case of the census estimates, people not lawfully present and therefore ineligible for expanded Medicaid. As a result, estimates for individual districts may be higher or lower than the true count of people in the Medicaid gap, particularly if the composition of the low-income uninsured by age or immigration status differs substantially among districts within a state.