Congress must close the Medicaid coverage gap once and for all

If a state ever deprived its residents of a necessity like food or water, we would demand the federal government’s urgent intervention. If the malnutrition and suffering that followed disproportionately hurt certain populations, we would call this an issue of justice and equity.

For the past seven years, not one state, but a dozen, have refused to expand Medicaid coverage to people under the Affordable Care Act (ACA), denying millions access to affordable healthcare coverage. In most countries, access to health care — like access to food and water — is properly regarded as a fundamental human right. Yet neither generous federal financial incentives, evidence of the health benefits of Medicaid expansion, nor the worst pandemic in a century have persuaded these states to change course. Waiting for them to act is no longer a viable option. It is time for a robust federal response to expand Medicaid in these 12 states.  

The ACA faced partisan opposition from the outset. An early challenge led to the Supreme Court’s ruling that states no longer were required to expand their Medicaid programs. In the wake of that ruling, political considerations in some states won out over the health and well-being of their residents. Today, we can clearly see that states that have not expanded their Medicaid programs are neglecting some of their most vulnerable populations. An overwhelming body of evidence shows that state expansions of Medicaid have provided health insurance for millions, improved health outcomes for beneficiaries and boosted state economies. Just as a person’s zip code can dramatically influence one’s opportunities and even life expectancy, the state in which a person lives today can determine whether they have access to basic medical care. As we have seen repeatedly throughout the COVID-19 pandemic, access to care can determine whether a person lives or dies.

Opponents in states that have not expanded Medicaid often cite costs as the reason. This argument has little merit. Consider the suite of financial incentives that a state would receive if it expanded Medicaid today. Under the ACA, the federal government would cover 90 percent of the cost of expansion for newly covered adults. Under the American Rescue Plan Act, that state would receive an additional five percentage point increase in the federal matching rate for two years. In other words, the federal government would bear the vast majority of the expansion costs while that state would reap the health and economic benefits. Even so, states have not budged.  

Once again, we have a situation in which the color of one’s skin determines one’s opportunity for health. Black and Brown people are affected disproportionately by the Medicaid coverage gap. More than 60 percent of the 2.2 million adults who would be covered if the 12 holdout states expanded Medicaid are people of color, according to the Center on Budget and Policy Priorities (CBPP). A new CBPP report released today sheds additional light on this uninsured population. The racial and ethnic disparities are stark: Blacks are 14 percent of the U.S. population but 28 percent of the population impacted by the coverage gap, while Hispanics are 18 percent and 28 percent, respectively. Among the adults in the coverage gap, 15 percent have a disability, while 1 in 3 are parents with children at home. The report also notes that most adults in the coverage gap are employed, but in jobs that are disproportionately less likely to offer health insurance — making Medicaid access even more essential. The report reinforces that populations disproportionately affected by COVID-19 are the same populations most likely to be uninsured. These are not coincidences, but patterns that reflect our nation’s past and present. 

Congress can take several paths to end this coverage gap, from a federalized Medicaid program to full subsidy coverage under the ACA’s health insurance exchanges. A debate over the specifics of these and other proposals is warranted; we should strive for the quickest and most cost-effective approach that covers the most people. But we must start with the principle that access to high quality, affordable health care is a fundamental right. Accordingly, it is not a question of whether Congress should act, but when. If Congress stands down, it will be reinforcing an uncomfortable and lamentable truth about this country: healthcare is a luxury, available to some but not all. Congress must not allow this moment of opportunity to pass. 

I come to this not just as the head of the nation’s largest health philanthropy, but as a practicing general pediatrician. I have treated uninsured children and their families and have seen the toll. Many live in fear that they won’t be able to receive the care they need if they get sick; that their children won’t grow up healthy; that a sudden, serious illness could bankrupt them. No one should have to live with that fear. I know, too, that simply closing the Medicaid coverage gap will not solve our coverage problem and that more will need to be done to increase access and affordability. These additional steps should include making marketplace plans more affordable, lowering prescription drugs costs and reforming Medicare Part D benefits. We must also reform Medicaid itself to ensure more uniformity in what state plans cover and at what rates the program reimburses providers; the most generous Medicaid benefits should not be reserved for people in certain states. Ultimately, we must find a way to guarantee the right of every person in the United States to access quality care no matter their skin color, income level, or zip code.

Despite the considerable coverage gains over the past decade under ACA, about 30 million people in the United States still lacked health insurance when the pandemic began, and the number of uninsured will remain too high even if Congress is successful in this effort. But in our drive toward universal health insurance, there is no better place to start than with closing the Medicaid coverage gap and there is no more critical time to get the job done than right now.   

Richard E. Besser, a physician, is president and chief executive of the Robert Wood Johnson Foundation in Princeton, N.J. and former acting director of the Centers for Disease Control and Prevention. Follow him on Twitter: @DrRichBesser