This issue brief contains corrections.
While several provisions of the Affordable Care Act have gone into effect, there is still one large hurdle to ensuring full implementation of the law in 2014: expanding Medicaid programs in all 50 states. Without this expansion, 11.5 million Americans whose incomes are too high to qualify for existing Medicaid coverage but too low to afford participation in the new health care exchanges set up by the law could go without insurance.
In June 2012 the Supreme Court ruled that Medicaid expansion was an optional provision of the Affordable Care Act, or ACA, and that states could not be penalized for refusing to expand their programs. House Republicans, however, have harshly criticized all components of the ACA, including the Medicaid expansion. The House of Representatives has voted more than 30 times to repeal the legislation, and already 13 states have refused to expand their Medicaid programs, despite the fact that the costs to the states will be modest. In some cases, states will even experience a net gain.
In the face of such obstacles, faith leaders and advocates from diverse traditions across the nation are urging governors and state legislators to do the right thing and expand their Medicaid programs to cover eligible, uninsured citizens. Faith leaders have a long history of supporting Medicaid as part of their anti-poverty work. Many faith communities run clinics or hospitals that provide health care to low-income people who lack health insurance, and they know firsthand the needs of their communities. In addition, faith communities deeply believe in providing protection and care for the most vulnerable in our society. Because of their expertise, their familiarity with their communities, and their spiritual beliefs, faith communities have been key participants in coalitions—joining with hospitals, businesses, economists, health care experts, advocates, and others—to urge states to expand their Medicaid programs and provide much-needed health care to their citizens.
Why we need to expand Medicaid
The Medicaid expansion will substantially strengthen states’ safety nets for their poorest residents at little cost to states. If enacted, the expansion covers all people with incomes up to 138 percent of the poverty line, which in 2013 is $15,417 for individuals and $26,347 for a family of three. The federal government will pay for 100 percent of the expansion population until 2017. After that the federal government’s match rate will start to decline, but even when the state contribution rates hit their peak in 2020, states will only be responsible for 10 percent of the costs. This allows already cash-strapped states to spend less money on costly uncompensated care and frees up resources to be used elsewhere.
Without the expansion as intended under the Affordable Care Act, millions of low-income Americans will fall into a coverage gap and be excluded from health care insurance. When writing the law, Congress intended that the poorest Americans would gain health care coverage through Medicaid, while those with slightly higher incomes would be able to buy private coverage through the exchanges with the assistance of federal subsidies. In states where the Medicaid program is not expanded, many low-income workers and families will be ineligible for Medicaid, as well as for the subsidies under the Affordable Care Act that help people above the poverty line afford health care coverage through an exchange plan.
A person with income at 90 percent of the federal poverty line in a state that does not expand Medicaid, for example, would be forced to pay the full price for insurance coverage. Someone in the same state earning slightly more—at 100 percent of the federal poverty line—would receive a federal subsidy to make purchasing coverage through the state’s exchange more affordable. Within this coverage gap, those living just above the poverty line will be forced to pay higher premiums for their coverage. Those living below that level almost certainly will still be without insurance and paying extremely high out-of-pocket costs. These financial burdens will also affect families who support the elderly or other low-income individuals, and health care providers who will absorb the health costs of those without insurance and those who rely on hospitals or charitable centers for their health care.
Why faith leaders and advocates are important allies
Faith-based coalitions addressing health care are diverse, in part because the issue is an important moral value within virtually all faith traditions. Religious advocates have created coalitions of Catholic, Protestant, Jewish, Buddhist, Muslim, Unitarian Universalist, and other faiths because protecting the poor and sick is an essential tenant of all major religions. Inspired by these values, faith communities have long spoken out for reforming the health care system to ensure that the vulnerable have access to care. These communities have found common ground and repeatedly collaborated on addressing local, national, and global health concerns.
Most faith communities have long supported Medicaid as an important safety net to protect the poor and sick. In fact, faith groups filed an amicus brief in support of Medicaid expansion under the Affordable Care Act, articulating the moral imperative for the program. In 2011 many religious denominations signed an interfaith statement in support of Medicaid and Medicare because of their protection of what is “at the heart of our sacred texts”—caring for the most vulnerable, particularly America’s low-income women, men, children, and people with disabilities.
Building on established, successful networks
Faith leaders and advocates have been able to build upon already-established networks and structures that were active in the Affordable Care Act of 2010. As key advocates in supporting the ACA, the U.S. Conference of Catholic Bishops, the United Methodist Church, the Evangelical Lutheran Church in America, the Episcopal Church, the Union for Reform Judaism, the Central Conference of American Rabbis, and many others engaged in the health care debate and were key to the bill’s passage, developing staff policy expertise, religious resources, and networks of organizers. These organizations have continued to champion the law, and denominational staffers and coalitions, such as the Washington Interreligious Staff Community Health Care Working Group, are now working to expand Medicaid.
Faithful Reform in Health Care, an interfaith coalition of organizations founded to advocate for health care reform, has continued to educate and connect faith communities through monthly conference calls to share best practices related to implementation of the ACA, including Medicaid expansion. Similarly, the National Council of Jewish Women, or NCJW, is working with its local affiliates in Missouri, Texas, Illinois, Pennsylvania, and elsewhere, as well as with interfaith coalitions, to expand Medicaid. Last spring, 350 NCJW advocates came to Washington, D.C., to learn more about Medicaid as an economic justice issue.
In Texas, Dallas Area Interfaith began several years ago to advocate for health care reform. After speaking with the more than 3,000 members of their group, Dallas Area Interfaith determined that health care was a primary concern within their community and began advocacy for the ACA. When Gov. Rick Perry (R-TX) announced last July that he would not expand Medicaid, the group sprang into action once again.
Gwen Lummus, chair of the health care committee at Dallas Area Interfaith, said faith leaders felt it was unacceptable for a state as wealthy as Texas—with the highest rate of uninsured people in the nation—to refuse expanding Medicaid to 1,798,314 more Texans if there was an opportunity to do so. Even though they knew it would be difficult to push Gov. Perry and the Republican-majority legislature to reverse their stance, the coalition of religious leaders began working with other faith congregations in the state to build upon the networks established during the health care debate and to raise public awareness and create political pressure for the expansion.
The group held private meetings with business owners, community leaders, hospitals, and elected officials. They sponsored public events, press conferences, and rallies, including one with more than 200 faith leaders from diverse faith traditions on the steps of the Capitol in Austin. They also garnered more than 5,000 signatures from people of faith calling for Medicaid expansion. Although Gov. Perry and the Republican state legislature refused to budge, the efforts of faith communities received statewide attention, and Gov. Perry has had to publically defend his decision three times since these faith groups began organizing.
Unusual coalitions are forming to make the case
Because faith communities are strong supporters of Medicaid, some of those who are otherwise against the Affordable Care Act—or who stayed on the sidelines during the debate—are joining forces to support Medicaid expansion. The U.S. Conference of Catholic Bishops is supporting this expansion despite the fact that it opposed the passage of the ACA and many of its members are currently involved in the lawsuits against the contraception-coverage requirement in the act.
Tracy Moebius of the First Unitarian Universalist Church of Columbus, Ohio, and a member of BREAD, an interfaith group that is advocating for Medicaid expansion in the state, points out that “expanding Medicaid is not the same as endorsing the Affordable Care Act.” In fact, conservative groups such as Ohio Right to Life and the Ohio Catholic Conference, who are opposed to the ACA, favor expanding Medicaid.
Ohio Right to Life President Mike Gonidakis has lobbied lawmakers for Medicaid expansion and suspects that “there’s a lot more people who identify themselves as conservatives who support this than those who do not. From a faith-based social conservative perspective, I struggle to find anybody who can tell me this isn’t a good idea.”
In Pennsylvania, 1,350 Roman Catholic nuns, priests, and brothers, representing 19 different religious congregations, signed a letter to Gov. Tom Corbett (R) urging him to expand Medicaid coverage to nearly 700,000 uninsured residents. In Louisiana, the Leadership Conference of Women Religious, the largest group of nuns in America, urged Catholic Gov. Bobby Jindal (R) to reverse his refusal to expand Medicaid, reminding him of Catholic teachings to care for the poor. In Mississippi, the annual Catholic Day at the Capitol focused on Medicaid expansion and brought parishioners from the Gulf Coast and Jackson to urge legislators to show compassion and extend Medicaid.
The role of faith-based health care providers
Faith-based clinics and hospitals can speak to the moral concerns of their communities. As providers, however, they can speak to the health needs of their communities as well.
Methodist Healthcare Ministries of South Texas, Inc., for example, a faith-based health-services organization that has provided care for low-income and uninsured families since 1995, found that Medicaid expansion for Texas residents will not only benefit the state’s uninsured but also the hospitals that serve them and the local governments that support them.* This is because hospitals and local governments spend far more on piecemeal health care for low-income people than the state will be expected to pay for the Medicaid expansion.
What’s more, under the ACA, hospitals will receive a lower disproportionate share of hospital payments because the health care law assumed the expanded Medicaid program would cover low-income Americans. Without the Medicaid expansion, which is designed to offset these cuts, hospitals in states that don’t expand will be financially strained.
Robin Bachman, assistant vice president of government affairs and public policy at Sisters of Charity Health System, a nonprofit Catholic health system that operates a medical center in downtown Cleveland, Ohio, has also expressed concern about the loss of federal funding without the expansion of Medicaid in her state. “If the General Assembly does not expand Medicaid,” she said, “they are making it much harder for us to do our work.”
Clinics are also facing financial strains due to an increase in demand; there are simply more patients. This increase is due to higher rates of unemployment, with workers having lost their insurance as a result of losing their job, and underemployment, with workers not receiving health insurance in the first place. In Kansas, two faith-based clinics from the Sisters of Charity of Leavenworth Health System experienced a 32 percent increase in patient visits last year alone, due mainly to these high rates of unemployment and underemployment. The clinics are hoping the expansion will go into effect in Kansas so that they can support the increased demand for health care.
Across the country, faith-based providers such as the Catholic Health Association, as well as nonprofits that provide care, such as Catholic Charities of Mississippi and Idaho, are actively supporting Medicaid expansion. Jeff Korsmo, president and CEO of Via Christi Health, the largest health care system in Kansas, wrote a column in The Morning Sun saying that the religious founders of the hospital “instilled in our health ministry the moral conviction that every person deserves access to health care” and that Medicaid expansion was both the morally and fiscally right thing to do.
How faith communities are helping
Faith leaders have given a voice to important policy issues throughout American history, providing a moral and values framework and calling Americans and their representatives to action when policies do not reflect the nation’s societal values. Once again, faith groups from diverse religious communities are speaking up to raise public awareness about the Medicaid expansion.
Giving visibility to the issue and articulating the value
Last September more than 100 faith leaders sent a public letter to governors in seven states, urging them to expand Medicaid. Rev. Jennifer Butler, executive director of Faith in Public Life and one of the signatories, said, “It’s unconscionable that politicians would even consider refusing to accept” the expansion since it will “save lives and alleviate suffering for poor families without straining state budgets.”
Sister Simone Campbell, executive director of NETWORK, a national Catholic social justice lobby, and organizer of “Nuns on the Bus,” a tour that called for an economy for the 100 percent, called Medicaid expansion “a pro-life stance” because it assists low-income Americans in all stages of life. A New England Journal of Medicine study found that the adult death rate dropped by 6 percent in states that have already expanded Medicaid. Similar to the earlier bus tour, the Catholic sisters are now touring states by bus to call for a health care system that includes all Americans. “We are all our brothers’ and sisters’ keepers,” said Sister Mary Ellen Lacy of NETWORK. She believes it is important to ignite a national conversation that will spur Americans to hold governors responsible for their decisions.
Educating local communities about state programs
A significant hurdle to the successful implementation of several components of the Affordable Care Act is the lack of public awareness about the benefits of those components, including Medicaid expansion. Even though it has been more than three years since the Affordable Care Act became law, for instance, two-thirds of uninsured adults say they do not know what it means for them, according to a poll by the Kaiser Family Foundation. As community educators and conveners, faith leaders and advocates are using their institutional resources and prominent voices to share information about health care reform with their congregants and communities.
Faith leaders have disseminated information through congregational newsletters and pamphlets, information sessions at support groups and adult education classes, healing and spiritual services, and other meetings. This is not a new role for faith leaders, who have long engaged in educational campaigns around health care and prevention, such as smoking, heart disease, diabetes, and HIV/AIDS.
In Illinois, the Campaign for Better Health Care last year trained 32 faith leaders on the health care law, focusing especially on the new state exchanges and Medicaid expansion. These leaders are now raising awareness and disseminating information within their congregations. The Campaign for Better Health Care also supports an annual faith campaign called “Sound the Alarm,” which aims to raise awareness on matters of health care justice. This year more than 150 congregations participated by ringing bells or playing other instruments relevant to their religious services and preaching sermons, holding vigils, sponsoring forums, and circulating church bulletins that included information about the state exchange program and Medicaid expansion.
Faith leaders are also teaming up with health care and advocacy organizations such as Families USA and Raising Women’s Voices. These groups provide state-based resources through reports and educational forums to spell out the benefits of Medicaid expansion, including how many dollars the state can save by instituting it. These collaborations equip faith leaders with the knowledge and resources to supplement their moral arguments with medical and economic information.
Coming together across faiths for state-level action
Faith communities are joining across denominations and faith traditions to urge their state legislators to expand Medicaid. National groups such as NETWORK, the National Council of Jewish Women, and Faithful Reform have provided toolkits or other support to local leaders. Because each state has its own political landscape and will be uniquely affected by the expansion, however, local groups are leading on-the-ground advocacy efforts.
Through public sign-on letters, meetings with elected officials, vigils, and public rallies, local leaders are banding together to make the moral case for the expansion. Missouri Faith Voices, a statewide network of 200 congregations and faith-based community organizations, has made the Medicaid expansion a key component of its work. More than 200 clergy from within the network met with Missouri Gov. Jay Nixon (D) and 80 state legislators to discuss the theological roots and community impacts of the potential expansion. Later, after an unsuccessful meeting with Sen. Kurt Schaefer (R), clergy published an open letter and pressed for a meeting with the editorial board of The Columbia Daily Tribune to continue to push for the expansion.
Other groups have used advocacy days and rallies to reach lawmakers. In South Carolina, the South Carolina Christian Action Council, which represents 1 million churchgoers, organized an advocacy day to urge Gov. Nikki Haley (R) to expand Medicaid. In Oklahoma, an ecumenical group of faith leaders have participated in rallies and news conferences at the state capitol to urge Gov. Mary Fallin (R) to reconsider her decision to refuse these federal funds. In Tennessee, Clergy for Justice delivered baskets of loaves of bread and fish to legislators, a symbol of the story of Jesus feeding the masses when there was barely enough for a few.* Rev. Thomas Kleinert, senior minister of Vine Street Christian Church in Nashville and a member of the group, believes the opportunity for thousands of Tennesseans to gain access to health care is the opportunity to “strengthen the fabric of our families and communities.” According to Kleinert, “We aren’t called to be miracle workers who do wonders with scarce resources; rather we are called to fully participate in the ongoing miracle of overflowing divine generosity and human community.”
Success stories from the states
Since the 2012 elections, eight Republican governors—in Nevada, New Mexico, Arizona, New Jersey, North Dakota, Michigan, Florida, and Ohio—have broken from the mold and thrown their support behind the program. Gov. Chris Christie (R-NJ) said the choice to accept the Medicaid expansion was simple. “We are putting people first,” said Christie. “We have an opportunity to ensure that even a greater number of New Jerseyans who are at or near the poverty line will have access to critical health services beginning in January 2014.”
Many Americans, including representatives, have been moved by the moral call for the expansion. In New Mexico, the New Mexico Conference of Catholic Bishops, the New Mexico Conference of Churches, Lutheran Advocacy Ministry, and Comunidades en Acción y de Fé, joined a coalition of 50 secular community and health organizations to urge Gov. Susan Martinez (R) to expand Medicaid. In January Gov. Martinez announced that her state would participate in the program, potentially extending health coverage to nearly 170,000 low-income uninsured New Mexicans.
Similar victories have been won in Colorado and Arizona, where faith leaders organized by Together Colorado and the PICO National Network, a national network of faith-based community organizations, joined advocates to call for Medicaid expansion. Both states have plans to expand their Medicaid programs; Gov. Jan Brewer (R-AZ) even defended her decision by arguing its moral importance.
More work needs to be done
Where state lawmakers or legislatures continue to oppose the expansion of Medicaid, faith-based groups are continuing their fight by linking moral arguments with the financial incentives for the expansion.
In Ohio, for example, faith leaders won a significant victory, gaining Republican Gov. John Kasich’s support for Medicaid expansion by articulating the moral imperative of the program. In his State of the State address, Gov. Kasich cited his Christian beliefs as one of the reasons for his support of the expansion, saying, “I can’t look at the disabled, I can’t look at the poor, I can’t look at the mentally ill, I can’t look at the addicted and think we ought to ignore them.” Gov. Kasich, however, failed to gain enough support among his fellow GOP legislators to support the expansion. Faith groups across the state, such as BREAD, the Religious Coalition for Reproductive Choice, Greater Cleveland Congregations, the Ohio Council of Churches, and PICO groups, have continued to put pressure on legislators, joining with the larger campaign for Medicaid expansion, the Ohio Alliance for Health Transformation, to merge a moral argument with the financial argument.
Tracey Lind, dean of Trinity Episcopal Cathedral in Cleveland and co-chair of Greater Cleveland Congregations, a coalition of 40 religious groups that has called on the state to expand Medicaid, believes the financial implications and the moral value of the expansion go hand in hand. She believes it is important that the state does not lose out on the billions of tax dollars that will be spent in the state. “I think fiscal responsibility is another word for stewardship,” said Lind. “And I believe there is a moral imperative. I think it’s fiscal irresponsibility not to participate.” Medicaid expansion would extend health care coverage to 684,000 Ohioans and provide more than $53 billion in federal dollars, increasing not only health care coverage but also jobs and tax revenue for the state. Faith leaders in Ohio have been working to educate the public and their legislatures about these financial incentives through private meetings, public letters, and rallies.
Ohio faith leaders are not the only ones touting the impact of Medicaid expansion by the dollars saved by state and local communities. In Virginia, faith leaders are sharing a study by the Commonwealth Institute that found the state can make the Medicaid expansion pay for itself, netting $555 million over the next eight years. In Texas, Dallas Area Interfaith often explains the Medicaid expansion program as a return of tax dollars to state and local communities, and that to reject the expansion is to give Texas money to the federal government, a framing that resonates with many in the state.
In Oklahoma, the financial argument has been an important piece of faith leaders’ organizing efforts. Rev. Stan Basler of Oklahoma City stressed the importance of both the financial argument and the moral argument in a NewsOK op-ed last April:
The choice is between sustaining the lives of the poor versus speculation about financial sustainability three years from now. In the meantime the health care-related economy should grow and nonurban medical care will be bolstered. Most importantly, lives will be saved, as will the dignity of the poor and working poor.
Faith communities across the country are engaged on the issue of Medicaid expansion because it will impact their congregants and communities. But these faith communities and their leaders are not losing hope.
Because a state can join the Medicaid expansion program at any time in the future, advocates have vowed to continue to organize until their legislatures support the expansion. Successful advocacy efforts this year are models for other states that continue to push for reform.
Where secular advocates have united with faith leaders to ensure that legislatures are educated about the financial incentives, and where citizens are made aware of the health benefits as well as the moral injustice of denying low-income workers and families access to care, coalitions have been able to build strong movements in support of the expansion.
Eleni Towns is a Research Associate with the Faith and Progressive Policy Initiative at the Center for American Progress. For more on this initiative, please see its project page.
* Correction, July 23, 2013: The original version of this issue brief incorrectly stated the year that Methodist Healthcare Ministries of South Texas, Inc., began; the correct year is 1995. The brief also incorrectly stated the name of Clergy for Justice.