The ACA Coverage Gap & Health Disparities

Posted onAuthorSatcher Health Leadership Institute

This Journal Club post is brought to you by

Harry J Heiman, MD, MPH

and

The Satcher Health Leadership Fellows

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Lack of access to health insurance has long been recognized as a critical barrier to health care and a key driver of health and health care disparities. While the Affordable Care Act was envisioned as a comprehensive solution to the challenge of uninsurance among impoverished and low-income populations in the United States, variable state-level participation in the ACA’s Medicaid expansion, in the wake of the June 2012 Supreme Court decision, has created the unanticipated reality of a continued insurance gap for many of the most vulnerable.

A recent report by the Kaiser Family Foundation[1] reveals a number of disturbing new realities:

States electing not to expand Medicaid are largely the same states that had not expanded coverage to impoverished adults in the past. With the exception of Wisconsin, none of the other non-expansion states provide Medicaid coverage for non-disabled childless adults living below the poverty level. Similarly, most of the non-expansion states provide limited Medicaid coverage for parents living below the poverty level. The average cut off is <47% of the federal poverty level (FPL).

As a result, in contrast to those with incomes > 100% FPL who are now eligible for premium subsidies to buy insurance through the new Health Insurance Marketplaces, those below 100% FPL in non-expansion states have no real options for obtaining health insurance coverage.

What is the likely impact of this coverage gap for poor individuals and communities already experiencing significant health disparities?

[1] Kaiser Family Foundation. The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid. October 23, 2013. Download at http://kff.org/health-reform/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/ 

 

Cutting Off Our Nose to Spite the Poor?

by Tee Gee Wilson, MD  

Medicaid helps people. It provides essential health care coverage and security from further impoverishment. Health care coverage is, not surprisingly, associated with better health outcomes.

Medicaid expansion helps states. Expansion under ACA uses the federal pool of tax dollars into which all states pay to fully fund expansion from 2014 through 2016 and to fund an average of 93% of costs through 2020 and 90% thereafter. The current federal match rate ranges from 50 – 73%. Expansion would lower the human costs and dollar costs that accrue from lack of coverage.

In its July 2013 analysis, the Kaiser Family Foundation estimated that 21 states, representing 4.9 million of the 10 million who could be covered by Medicaid expansion, will refuse expansion. Roughly half of the 4.9 million uninsured who could be helped but won’t be reside in three states – Texas, Florida, and Georgia, all former Confederate states on or close to the Mexican border with attendant large populations of black and brown people, many of them poor. The poor in non-expansion states will continue to become even poorer, suffer more illness and die earlier. A disproportionate percentage of those who suffer this misery will be people of color. The non-expansion states will gain nothing except, perhaps, an increase in moral debt.

 

Medicaid non-expansion and the ACA

by Winston Abara, MBBS, PhD

Unfortunately the coverage gap due to the non-expansion of Medicaid in these states will ensure that the affected individuals will continue to lack access to healthcare. These affected persons include some of the most vulnerable in the society who also reside in some of the most disadvantaged communities. The impact of this decision will ensure that disparities in access to health and healthcare by members of these groups and their communities will continue to exist which will manifest as disparate health outcomes.

It is also noteworthy that most of the states that have refused to expand Medicaid coverage are states that already have some of the worst health and poverty indices nationally. Despite the reasons put forward by these non-expansion states, I will suggest that the non-Medicaid expansion states should take a cue from states like Arkansas and Kentucky that have worked around their reservations about Medicaid expansion to ensure that their citizens are not denied access to health and healthcare.