Medicaid Expansion Study - Coverage Gaps in States Not Expanding

Written by: Christina Merhar
Published on December 19, 2013.

One of the intentions of the Affordable Care Act (ACA), according to the administration, is to increase health insurance coverage, and decrese the rate of uninsured Amercians. A key provision to accomplish this goal was the expansion of Medicaid to adults with incomes at or below 138% of the federal poverty level (FPL). While Medicaid expansion was intended to occur nationwide, it was effectively made a state option by a 2012 Supreme Court decision.

According to a recent analysis by Kaiser Family Foundation (KFF), in states that do not expand Medicaid, many poor uninsured adults will not gain a new coverage option and will likely remain uninsured. This article provides an overview of where states stand with Medicaid expansion, and what that could mean for uninsured rates in those states.

Medicaid Expansion - Where States Stand as of December 2013

Here is where states currently stand with Medicaid expansion:

  • 26 states, including DC, are implementing Medicaid expansion
  • 2 states are seeking to move forward with Medicaid expansion
  • 23 states are not moving forward with Medicaid expansion at this time. (For an introduction to Medicaid expansion, see this article.)


Image source: KFF

Health Insurance Coverage Gaps 

In states not expanding Medicaid, nearly five million low-income uninsured adults will fall into what is being called a “coverage gap.” These individuals would have been eligible for Medicaid if their state had chosen to expand eligibility. Without Medicaid expansion, they remain ineligible for Medicaid and do not earn enough to qualify for premium tax credits to purchase Marketplace coverage, which begins at 100% FPL. Most of these individuals have very limited coverage options and are likely to remain uninsured.


Image source: KFF

KFF's analysis found:

  • Today, there are significant racial and ethnic disparities in health coverage among adults. Overall, among adults, people of color are more likely to be uninsured than Whites (27% vs. 15% respectively), with Hispanics at the highest risk of lacking coverage (33%).

  • Given these high uninsured rates, the Medicaid expansion offers a particularly important opportunity to increase health coverage among people of color. Overall, more than half (53%) of uninsured adult people of color have incomes at or below the Medicaid expansion limit.

  • However, in states that do not expand Medicaid, millions of poor adults will be left without a new coverage option, particularly poor uninsured Black adults residing in the South, where most states are not moving forward with the expansion. Four in ten uninsured Blacks with incomes low enough to qualify for the Medicaid expansion fall into the gap, compared to 24% of uninsured Hispanics and 29% of uninsured Whites. These continued coverage gaps will likely lead to widening racial and ethnic as well as geographic disparities in coverage and access.

Click here to read the full report, via

Where does your state stand?

Originally published on December 19, 2013. Last updated December 19, 2013.


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