Medicaid expansion is critical to achieving the Affordable Care Act’s (ACA) goal of providing access to affordable health coverage. The expansion was originally intended to be required of all states participating in the Medicaid program, but the 2012 Supreme Court ruled it optional. This has led 23 states to refuse to participate as of this writing and approximately four million uninsured Americans now fall into a ‘coverage gap’ where they earn too little to qualify for subsidized private insurance but too much for Medicaid under current eligibility rules. Thanks to the ruling, we now have a two-tiered health care system, where expansion states offer affordable coverage to most of their residents and significant disparities in coverage persist in non-expansion states.
For those experiencing homelessness, the difference could not be more stark. Prior to the ACA, a majority of those who were homeless lacked insurance and access to comprehensive health services. This has changed in expansion states, with significant increases in coverage being noted at Health Care for the Homeless (HCH) projects (see insurance status figure below; click on the image for a larger version). In non-expansion states, most people experiencing homelessness fall into the coverage gap and remain uninsured since few earn as much as 100% of the Federal Poverty Level, the amount of income required to qualify for subsidized private insurance. A recent analysis estimated between 87-99% of the 175,000 uninsured HCH patients in non-expansion states will remain uninsured without Medicaid expansion.

The Kaiser Family Foundation and the National HCH Council recently published a report on the early impacts of expansion and found the effects went well beyond simply insurance rates. HCH staff reported increased revenue for their organizations, improved access to care, and opportunities to fund creative solutions to homelessness. A second report from the Council focused on non-expansion states and in contrast found anxiety, anger, lack of access to comprehensive care and in some cases, unnecessary loss of life.

The economic case for expansion is also tremendously strong. The federal government will pay for 100% of the costs of expansion through 2016, then tapering off to 90% by 2021. Opponents of the expansion claim it is too expensive for states, but this does not hold up under scrutiny. Two recent reports show only modest increases in state Medicaid spending and project that non-expansion state spending will rise faster than spending in expansion states. This is in addition to the numerous studies that predict increased state revenues, reductions in state uncompensated care spending, and increased economic activity thanks to expansion.

On the policy merits, the choice to expand Medicaid is clear, but unfortunately fierce opposition persists. This hostility is formidable, based mostly on political and ideological concerns. This resistance can be overcome, as shown by the red states that have embraced Medicaid expansion and three recent proposals to expand in Utah, Wyoming, and Tennessee. Still, strong advocacy is needed to push these through the state legislatures.

Most state legislatures convene in early 2015 and national and state advocates should push hard for Medicaid expansion. At the national level, we can help our state affiliates collaborate, provide resources, and highlight the inequities in states’ decisions to continue to deny their residents affordable health care. A Congressional Medicaid Expansion Caucus is doing just that and the National HCH Council and others are eager to assist. With the midterm elections behind us and the political potency of the ACA starting to fade, there is no excuse. Expand Medicaid now.