The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid

The economic downturn and switch in government are probable to bring renewed care to gaps in Medicaid coverage in states that have not expanded eligibility under the Affordable Care Act ( ACA ). In late months, millions have gained health insurance coverage through Medicaid as a result of the economic effects of the pandemic arsenic good as the care of eligibility and continuous coverage requirements tied to access to temp enhanced Medicaid matching funds. however, in the 12 states that have not adopted the Medicaid expansion as of January 2021, Medicaid eligibility for adults remains specify. At a fourth dimension when many are losing income and potentially health coverage during a health crisis, these eligibility gaps leave many without an low-cost coverage option and could contribute to emergence in the uninsured rate. The Biden Administration is likely to make coverage expansion for low-income populations a precedence, including fill in the “ coverage col ” that exists for adults in non-expansion states .
Adults who fall into the coverage col have incomes above their state ’ s eligibility for Medicaid but below poverty, the minimum income eligibility for tax credits through the ACA market ( Figure 1 ). Medicaid eligibility for adults in states that did not expand their programs is quite express : the medial income restrict for parents in these states is merely 41 % of poverty, or an annual income of $ 8,905 for a syndicate of three in 2020, and in closely all states not expanding, childless adults remain ineligible. Because the ACA envisioned low-income people receiving coverage through Medicaid, it does not provide fiscal aid to people below poverty for early coverage In contrast, in states that have adopted the ACA Medicaid expansion, Medicaid eligibility is extended to closely all low-income individuals with incomes at or below 138 percentage of poverty ( $ 17,609 for an person in 2020 ) .
This brief presents estimates of the number of people in non-expansion states who could be reached by Medicaid if their states adopted the expansion and discusses the implications of them being left out of ACA coverage expansions. It is based on coverage data from 2019, the most holocene year available. Because this data predates the pandemic and associate job and income loss, it is likely that the count of people in the coverage gap has grown since the depart of the pandemic, and these estimates may be a lower bandaged of how many people are presently in the coverage gap. An overview of the methodology underlying the psychoanalysis can be found in the Data and Methods, and more detail is available in the Technical Appendices .

How Many Uninsured People Who Could Have Been Eligible for Medicaid Are in the Coverage Gap?

nationally, more than two million poor uninsured adults fell into the “ coverage break ” that results from state of matter decisions not to expand Medicaid ( Table 1 ), meaning their income was above Medicaid eligibility but below the lower limit for Marketplace premium tax credits. These individuals would be eligible for Medicaid had their country chosen to expand coverage. Reflecting limits on Medicaid eligibility outside ACA pathways, most people in the coverage break ( 77 % ) are adults without dependent children.

Adults left in the coverage gap are spread across the states not expanding their medicaid programs but are concentrated in states with the largest uninsured populations. More than a third base of people in the coverage gap reside in Texas, which has both a large uninsured population and very limited Medicaid eligibility ( Figure 2 ). nineteen percentage of people in the coverage col live in Florida, twelve percentage in Georgia, and ten-spot percentage in North Carolina. There are no uninsured adults in the coverage gap in Wisconsin because the state is providing Medicaid eligibility to adults up to the poverty level under a Medicaid release .
The geographic distribution of the population in the coverage gap reflects both population distribution and regional variation in state take-up of the ACA Medicaid expansion. The South has relatively higher numbers of inadequate uninsured adults than in early regions, has higher uninsured rates and more limited Medicaid eligibility than other regions, and accounts for the majority ( 8 out of 12 ) of states that opted not to expand Medicaid. As a solution, the huge majority of people in the coverage opening in 2019 occupy in the South ( Figure 2 ) .

What Would Happen if All States Expanded Medicaid?

If states that are presently not expanding their programs adopt the Medicaid expansion, all of the closely 2.2 million adults in the coverage gap would gain Medicaid eligibility. In addition, 1.8 million uninsured adults with incomes between 100 and 138 % of poverty ( most of whom are presently eligible for Marketplace coverage ) would besides gain Medicaid eligibility ( Figure 3 and Table 1 ). Though most of these adults are eligible for substantial tax credits to purchase Marketplace coverage, Medicaid coverage would likely provide more comprehensive examination benefits and lower premiums or cost-sharing than they would face under Marketplace coverage. For case, inquiry from early implementation of the ACA showed that coverage of behavioral health services, prescription drug drugs, reconstructive and habilitative services, and long-run services and supports may be more express in the Marketplace compared to Medicaid., In addition, research examining the population with incomes between 100-138 % FPL in expansion and non-expansion states finds that Medicaid expansion coverage produced far greater reductions than subsidized Marketplace coverage in average total out-of-pocket outgo, average out-of-pocket premium spend, and average cost-sharing spend .
A smaller number ( about 356,000 ) of uninsured adults in non-expansion states are already eligible for Medicaid under eligibility pathways in place before the ACA. If all states expanded Medicaid, those in the coverage col and those who are rather eligible for Marketplace coverage would bring the number of nonelderly uninsured adults eligible for Medicaid to more than 4.3 million people in the twelve current non-expansion states. The likely count of people who could be reached by Medicaid expansion varies by state ( table 1 ).


At a time when many need health care services due to the health wish crisis or confront passing of fiscal security due to the economic downturn, millions fall into the Medicaid coverage break due to their state of matter ’ s decision not to expand eligibility. The ACA Medicaid expansion was designed to address historically high uninsured rates among low-income adults, providing a coverage choice for people with limited access to employer coverage and specify income to purchase coverage on their own. In states that expanded Medicaid, millions of people gained coverage, and the uninsured rate dropped significantly as a resultant role of the expansion. however, with many states opting not to implement the Medicaid expansion, millions of uninsured adults remain outside the pass of the ACA and continue to have limited options for low-cost health coverage. In 2019 the uninsured pace in non-expansion states was about double that of expansion states ( 15.5 % vs. 8.3 % ) .
By definition, people in the coverage break have limited class income and survive below the poverty flat. They are likely in families employed in very low-wage jobs, employed half-time, or with a flimsy or unpredictable connection to the work force. Given the economic downturn and specify offer rates of employer-based coverage for employees with these work characteristics, it is probable that employer-based coverage is not a feasible choice for them .
It besides is unlikely that people who fall into the coverage gap will be able to afford ACA coverage, as they are not eligible for premium subsidies : in 2021, the home modal unsubsidized premium for a 40-year-old non-smoking individual buying coverage through the Marketplace was $ 436 per month for the lowest-cost silver plan and $ 328 per calendar month for a bronze design, which equates to closely eighty percentage of income for those at the lower income range of people in the opening ( below 41 % FPL ) and about a third gear of income for those at the higher income range of people in the opening .
If they remain uninsured, adults in the coverage col are probable to face barriers to needed health services or, if they do require and receive checkup care, potentially serious fiscal consequences. While the guard web of clinics and hospitals that has traditionally served the uninsured population will continue to be an significant informant of manage for the remaining uninsured under the ACA, this arrangement has been stretched in holocene years due to increasing demand and limited resources.

Most people in the coverage gap live in the South, leading submit decisions about Medicaid expansion to exacerbate geographic disparities in health coverage. In addition, because respective states that have not expanded Medicaid have large populations of people of color, state of matter decisions not to expand their programs disproportionately affect people of color, particularly Black Americans. As a result, submit decisions about whether to expand Medicaid have implications for efforts to address disparities in health coverage, access, and outcomes among people of color .
There is no deadline for states to opt to expand Medicaid under the ACA, and argument continues in some states about whether to expand. In 2020, two states ( Missouri and Oklahoma ) adopted the Medicaid expansion via ballot initiatives, and both states plan to implement expansion in mid-2021 ( these states are considered Medicaid expansion states in this analysis ). In addition, there will be new federal stress on encouraging expansion, either through legislative or administrative actions. Biden has proposed creating a Medicare-like populace option plan, which would be available to anyone and automatically embrace people with depleted incomes in states that have not expanded Medicaid. other possible legislative actions include reinstating the 100 % matching for states that newly adopt the expansion for a period of meter ( the current match rate for the expansion is 90 % ). The Biden Administration could besides can revise current presentation release policy or promote new waivers to focus on expanding coverage. Whether, and to what extent, these actions are implemented and extend Medicaid to people presently in the coverage gap will be a key policy issue for the approaching class .

Table 1: Uninsured Adults in Non-Expansion States Who Would Be Eligible for Medicaid if Their States Expanded,
by Current Eligibility for Coverage, 2019
State Total Currently Eligible for Medicaid Currently in the Coverage Gap
(<100% FPL)
Currently May Be Eligible for Marketplace Coverage
(100%-138% FPL**)
All States Not Expanding Medicaid 4,344,000 356,000 2,188,000 1,800,000
Alabama 217,000 13,000 127,000 77,000
Florida 833,000 43,000 415,000 375,000
Georgia 490,000 37,000 269,000 184,000
Kansas 90,000 7,000 45,000 37,000
Mississippi 179,000 12,000 102,000 64,000
North Carolina 404,000 32,000 212,000 161,000
South Carolina 207,000 19,000 105,000 84,000
South Dakota 30,000 2,000 16,000 11,000
Tennessee 256,000 30,000 118,000 108,000
Texas 1,534,000 101,000 771,000 662,000
Wisconsin* 87,000 57,000 0 30,000
Wyoming 17,000 2,000 7,000 8,000
NOTES: * Wisconsin provides Medicaid eligibility to adults up the poverty level under a Medicaid waiver. As a result, there is no one in the coverage gap in Wisconsin. ** The “100%-138% FPL” category presented here uses a Marketplace eligibility determination for the lower bound (100% FPL) and a Medicaid eligibility determination for the upper bound (138% FPL) in order to appropriately isolate individuals within the range of potential Medicaid expansions but also with sufficient resources to avoid the coverage gap. Totals may not sum due to rounding.
SOURCE: KFF analysis based on 2020 Medicaid eligibility levels and 2019 American Community Survey.
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