What States Have Registered For Medicaid Expansion

Advocates for expanding Medicaid in Kansas staged a protest outside the entrance to the statehouse parking garage in Topeka in May 2019. Today, twelve states take yet not expanded Medicaid. The biggest are Texas, Florida, and Georgia, merely at that place are a few exterior the South, including Wyoming and Kansas. John Hanna/AP hide caption

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John Hanna/AP

Advocates for expanding Medicaid in Kansas staged a protestation outside the archway to the statehouse parking garage in Topeka in May 2019. Today, twelve states accept still not expanded Medicaid. The biggest are Texas, Florida, and Georgia, but there are a few exterior the Southward, including Wyoming and Kansas.

John Hanna/AP

There are more than 2 million people across the United States who have no selection when it comes to health insurance. They're in what's known as the "coverage gap" — they don't qualify for Medicaid in their state, and make besides little money to be eligible for subsidized health plans on the Affordable Care Human action insurance exchanges.

Briana Wright is one of those people. She'southward 27, lives nigh Jackson, Miss., works at McDonalds, and doesn't have wellness insurance. Then to figure out her options when she recently learned she needed to have surgery to remove her gallbladder, she called Health Help Mississippi, a nonprofit that helps people enroll in health insurances.

Considering she lives in Mississippi, "I wasn't going to exist eligible for Medicaid — because I don't have children [and] I'm not pregnant," she tells NPR. When she had her income checked for Healthcare.gov, it was just shy of the federal poverty line — the minimum to qualify for subsidies. "It was $74 [short]. I was like, oh wow," she says.

Wright's inability to get a subsidized policy on Healthcare.gov is related to how the Affordable Care Act was originally designed. People needing insurance who were in a higher place the poverty line were supposed to be funneled via the federal and state insurance exchanges to private policies — with federal subsidies to assistance make those policies affordable. People who were under the poverty line were to be funneled to a newly-expanded version of Medicaid — the public health insurance programme that is jointly funded by states and the federal government. But the Supreme Court fabricated Medicaid expansion substantially optional in 2012, and many Republican-led states declined to expand. Today, there are 12 holdout states that take non expanded Medicaid, and Mississippi is one of them.

So, Wright is nevertheless uninsured. Her gallbladder is causing her pain, only she can't afford the surgery without shuffling household bills, and risking leaving something else unpaid. "I'm stressed out about it. I don't know what I'grand going to do," she says. "I'm going to just have to pay it out of pocket or go on some payment programme until it all gets paid for."

Hoping to finally notice a set for Wright and the millions similar her who are in Medicaid limbo, several teams of Democratic lawmakers have recently been hashing out several options — hoping to build on the momentum of the latest Supreme Court confirmation that the ACA is here to stay.

OPTION one: Sugariness-talk the 12 holdout states

The COVID-19 relief bill passed in March included financial enticements for these 12 states to expand Medicaid. Substantially, the federal regime will cover 90% of the costs of the newly eligible population, and an additional 5% of the costs of those already enrolled.

It'due south a good financial deal. An analysis past the nonprofit Kaiser Family Foundation estimates that the net benefit for these states would be $nine.half-dozen billion. Merely, so far — publicly, at least — no states have indicated they intend to take the federal government upwardly on its offering.

"If that is not getting states to motility, then that suggests that the deep root of their hesitation is non about financial constraint," says Jamila Michener, a professor of government at Cornell University and author of the volume Fragmented Democracy: Medicaid Federalism And Unequal Politics.

Instead, Michener says, the reluctance amid some Republican-led legislatures and governors to expand Medicaid may be a combination of partisan resistance to President Obama'south signature health police, and not believing "this kind of government intervention for these groups of people is advisable."

What'southward Next: When asked about progress on this front in an April press briefing, Biden's press secretary Jen Psaki said "the President is certainly supportive of — and an abet for — states expanding Medicaid," but did not respond a follow up about whether the White Firm was directly reaching out to governors regarding this option.

Option 2: Create a federal public pick to fill the gap

Some have advocated for circumventing these holdout states and creating a new, standalone federal Medicaid program that people who fall into this coverage gap could join. Information technology would be kind of like a tailored public option just for this group.

This thought was included in Biden's 2022 budget, which says, in office: "In States that have not expanded Medicaid, the President has proposed extending coverage to millions of people by providing premium-gratis, Medicaid-like coverage through a Federal public option, paired with financial incentives to ensure States maintain their existing expansions."

Merely it wouldn't exist simple. "That can be quite complex — to implement a federal programme that'south targeted to just these 2.2 million people across a handful of states," says Robin Rudowitz, co-managing director of the Medicaid program at the Kaiser Family unit Foundation, who wrote a recent analysis of the policy options.

It besides may exist a heavy lift, politically, says Michener. "Anything that expanded the footprint of the federal government and its function in subsidizing health care would be especially challenging," she says.

What's next: This thought was raised as a possible solution in a letter concluding month from Georgia's Democratic senators to Senate leaders, and Sen. Raphael Warnock said this week he plans to introduce legislation soon.

Choice three: Get effectually stubborn states by letting cities expand Medicaid

Instead of centralizing the approach, this side by side idea goes fifty-fifty more than local. The Comprehend At present Act, introduced by Rep. Lloyd Doggett, D-Texas, would empower local jurisdictions to expand Medicaid. And so, if you live in Austin, Texas, maybe you could become Medicaid, even if someone in Lubbock however couldn't.

The political and logistical challenges would be tough, policy analysts say. Logistically, such a program would require counties and cities to create new infrastructure to run a Medicaid plan, Rudowitz notes, and the federal government would have to oversee how well these new local programs complied with all of Medicaid's rules.

"Information technology does not seem feasible politically," Michener says. "The legislators who would have to vote to make this possible would be ceding quite a bit of power to localities." It as well might amplify geographic equity concerns, she says. People's access to health insurance would not just "exist arbitrarily based on what state you live in — which is the electric current country of diplomacy — It's as well going to be arbitrary based on what county you lot live in, based on what city you lot live in."

What's next: Doggett introduced the bill earlier this month. There'southward no guarantee it would go a vote on the House floor and — fifty-fifty if information technology did — it wouldn't survive a probable filibuster in the evenly divided Senate.

OPTION 4: Modify the ACA to open up the exchanges

A fourth idea, Rudowitz says, is to change the law to remove the minimum cutoff for the private health insurance exchanges, since "correct now, individuals who are beneath poverty are not eligible for subsidies in the market place." With this choice, states wouldn't be paying any of the costs, since the federal government pays premium subsidies, Rudowitz says, but "there are bug around beneficiary protections, benefits, out-of-pocket costs."

What'south next: This idea hasn't yet been included in any current congressional bills.

Volition any of these ideas come up to fruition?

Even with a variety of ideas on the tabular array, "there'due south no slam dunk option, it's a tough policy upshot," Rudowitz says. All of these would exist complicated to pull off.

It'due south possible Democrats will include one of these ideas in a reconciliation pecker that could pass without the threat of a Republican filibuster. But that nib has all the same to be written, and what will be included is anyone's gauge.

Fifty-fifty so, Michener says she's glad the discussion of the Medicaid coverage gap is happening, because it's sensitizing the public, as well every bit people in ability, to the problem and potentially changing the political dynamic down the line. "Even in policy areas where you don't have any kind of guaranteed victory, it is often worth fighting the fight," she says. "Politics is a long game."