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Medicaid: A Critical Health Safety Net Under Fire
Ten States, largely in the South, still choose not to expand their Medicaid programs under the Affordable Care Act. These states have some of the worst health inequities in the country.
Representative Image / Pexels
The nation's largest health insurance program Medicaid currently provides free or low cost to more than 83 million people in the US. Due to the Great Unwinding approximately 23 million people, including 3 million children, have lost or stand to lose coverage due to the end of pandemic-era continuous coverage protections.
Expanding Medicaid to close the coverage gap is one of the most significant ways states can increase coverage rates and achieve health equity. Yet 10 States, largely in the South, still choose not to expand their Medicaid programs under the Affordable Care Act. These states have some of the worst health inequities in the country.
Ethnic Media Services (EMS), in partnership with the Robert Wood Johnson Foundation, brought together experts to address the urgency of strengthening Medicaid and expanding coverage to ensure equitable access to healthcare for all. The panel included Katherine Hempstead, Senior Policy Adviser at the Robert Wood Johnson Foundation; Stan Dorn, Director of the Health Policy Project at UnidosUS; Martha Sanchez, Health Policy and Advocacy Director at Young Invincibles; and Joan Alker, Executive Director and Co-Founder of the Center for Children and Families at Georgetown University.
The panelists underscored that Medicaid is more than just a government program; it is a lifeline for millions of Americans. They called for immediate action to address the coverage gap, particularly in states that have yet to expand Medicaid.
Role of states in Medicaid
Medicaid and Medicare are sixty year old programs, unlike Medicare, which is a completely federal program, Medicaid was designed as a Federal State partnership, which means that there's both Federal and State money going to the program in each State, although the Federal Government spends much more in poorer states, explained the panelists.
Viewed as a whole, the Medicaid program is the largest single source of health insurance in the country, fragmented into 50 different state programs. Each state has their own Medicaid Agency. At least three quarters of the states actually contract the Medicaid program out to managed care organizations, MCS or insurance companies Therefore, the face of Medicaid looks different in different states. Each State names their own Medicaid program.
Medicaid touches almost everyone- largest healthcare provider in the country
Close to a quarter of the population is enrolled in Medicaid. Enrollees are children, pregnant women, low-income adults, also low-income seniors and people with disabilities. “So there's many, many people that are touched by the Medicaid program,” said Katherine Hempstead, Senior Policy Adviser at the Robert Wood Johnson Foundation at the briefing. The Medicare program doesn't cover long term services, it is Medicaid that supports individuals with disabilities and people with special healthcare needs, children and adults. It pays for the vast majority of long term services and supports low-income seniors.
“I myself have an adult son with a disability that has been in the Medicaid program and will be for the rest of this life. It's a very, very large program that touches many of us,” said Hempstead.
The coverage gap came with the expansion in Medicaid eligibility accompanying the Affordable Care Act.
The Affordable Care Act’s (ACA) expanded Medicaid coverage to nearly all adults with incomes up to 138 percent of the Federal Poverty Level ($20,783 for an individual in 2024) and provided states with an enhanced federal matching rate (FMAP) for their expansion populations. The Supreme Court ruled in 2012 that the expansion of Medicaid under the Affordable Care Act (ACA) was optional for States. Some States have chosen not to expand Medicaid under the ACA.
People below the poverty line or with low incomes are unable to qualify for assistance from the Affordable Care Act (ACA) marketplace because their state has not adopted the ACA Medicaid expansion. As of February 2024, 40 states and Washington, DC have adopted the Medicaid expansion.
“This creates a coverage gap where there are approximately 2 to 3 million people predominantly in populations of color who are in a very unfortunate and unfair situation,” said Hempstead. “Large States, like Texas and Florida have not expanded their coverage.”
On the other hand some states, like California, are expanding coverage to people regardless of their immigration status mostly through the Medicaid program and sometimes using the ACA marketplace or a combination of the two. Some states provide coverage to children, some have covered adults. Illinois for instance covered seniors.
Losing Medicaid eligibility due to redetermination
“It's very hard for lots of people to stay on Medicaid, even though they remain eligible because of the bureaucratic hoops that people need to jump through.Those who are eligible for Medicaid must ensure they keep their coverage,” said the panelist.
The federal COVID-19 emergency froze the process of annual Medicaid eligibility checks known as redetermination. Since the emergency was lifted in May 2023, redetermination has begun again. Sixty nine percent were disenrolled, not because they were ineligible, but because of paperwork and proceduralities.
“Due to either slight variations in income or administrative implementation issues, losing their coverage and having to get back on is most inefficient," said Hempstead. “It's very costly to the individual. It's also costly to state agencies.
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