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How 19 Republican-Led States Trap People in Poverty

Increasing Medicaid income thresholds helps disabled Americans get back to work. (Volume 9, Issue 24)

People with disabilities make up approximately 20% of the U.S. population and are subject to significant employment, income, housing, and health disparities. Many disabled Americans have health insurance through Medicaid as their disability qualifies them for the program. Historically, strict income limits also applied, which limited Medicaid eligibility to people who also had incomes well under the federal poverty level (FPL).

Source: Christine Gleason (Flickr/CC)

Under the Affordable Care Act, most states expanded their Medicaid programs, increasing income eligibility to 138% FPL. However, in the 19 states that have not expanded, the average monthly income limit is just 85% FPL. In those non-expansion states, Medicaid eligibility remains contingent on living in poverty. Politically, the discussion often revolves around whether programs like Medicaid de-incentivize workforce participation for people with disabilities because people gain access to insurance without having to work. A recent study rebuts this line of thinking and supports the conclusion that more Americans with disabilities will participate in the workforce if able to maintain Medicaid coverage.

The study compared employment rates for people with disabilities in states that expanded Medicaid and non-expansion states. The results demonstrated that people living in expansion states were significantly more likely to be employed and significantly less likely to be unemployed due to their disability.

Politicians who oppose Medicaid and the Affordable Care Act often simplify this issue by claiming that people take advantage of the system. But for individuals experiencing this problem, there are no good options. Pursuit of employment that will get them out of poverty disqualifies them from Medicaid, yet private insurance remains unaffordable and out of reach.

This study demonstrates that allowing people with disabilities to maintain health insurance coverage through Medicaid while also making enough money to live above the poverty line is a better solution for everyone. The authors point out that Medicaid expansion may also result in long-term cost savings to state and federal governments to the extent that higher income and asset accrual improve health outcomes and reduce the financial burden on the health system as a whole. It is important for elected officials to look at long-term impacts for their constituents, even when those outcomes may not be realized in time to support their own re-election.


Objectives. To use data from the Health Reform Monitoring Survey (HRMS) to examine differences in employment among community-living, working-age adults (aged 18–64 years) with disabilities who live in Medicaid expansion states and nonexpansion states. 

Methods. Analyses used difference-in-differences to compare trends in pooled, cross-sectional estimates of employment by state expansion status for 2740 HRMS respondents reporting a disability, adjusting for individual and state characteristics. 

Results. After the Affordable Care Act (ACA), respondents in expansion states were significantly more likely to be employed compared with those in nonexpansion states (38.0% vs 31.9%; P=0.011). 

Conclusions. Prior to the ACA, many people with disabilities were required to live in poverty to maintain their Medicaid eligibility. With Medicaid expansion, they can now enter the workforce, increase earnings, and maintain coverage.

PMID: 27997244 Hall JP, et al. AJPH.2016; e-pub ahead of print.


Megan Douglas, JD
About Megan Douglas, JD

Megan Douglas is the Associate Director of Health Information Technology Policy in the National Center for Primary Care at Morehouse School of Medicine in Atlanta, GA. She is a licensed attorney and focuses on health policy and its impact on individuals from underserved communities. She was a 2012-13 Health Policy Leadership Fellow under Dr. David Satcher, 16th Surgeon General of the United States. Megan has worked on health policy issues related to neurodevelopmental disabilities, HIV and AIDS discrimination, racial and ethnic health disparities, and individuals identifying as LGBTQ. In her current role, she is looking at the impact of Health Information Technology (HIT) policies on healthcare providers who serve underserved communities and is identifying ways to leverage HIT to improve health outcomes for the underserved. Contact: Website | Facebook | Twitter | Google+ | More Posts