In health care rollout, Medicaid expansion a priority

Much of the attention this week is rightly focused on the opening of the new marketplaces, or exchanges, established by the Affordable Care Act (ACA), which facilitate shopping for health-insurance policies. An aspect of the ACA that will also be crucial to its success but has a much lower profile is the full implementation of the Medicaid expansion in every state, as envisioned by the law.

The ACA promises to move the United States closer to universal coverage, with 94 percent of Americans projected to be covered if it were fully implemented. In 2012, according to recent Census Bureau data, only 84.6 percent of Americans have health insurance. Children are doing much better than adults, with coverage of more than 92 percent already, thanks to the government’s long-standing commitment to extending public coverage through Medicaid and the Children’s Health Insurance Program (CHIP).

The ACA sought to build on this success with children by extending coverage through Medicaid to their parents and other adults with incomes below 133 percent of the federal poverty line. (For a single adult, that ACA threshold is just above $15,000.) Many states have chosen not cover those adults. This expansion of Medicaid coverage is accompanied in the law by extremely generous federal funding: For the first three years, the feds will foot the entire bill. Over 10 years the federal share declines to 90 percent — still the highest Medicaid matching rate we have seen. Yet today only half the states are moving forward with accepting the funds — now each state’s choice rather than a requirement because of the U.S. Supreme Courts 2012 verdict that upheld the vast majority of the ACA but, disturbingly, made the Medicaid expansion optional.

Stubborn political resistance — with Republican Party subsets in state legislatures often blocking other Republicans’ efforts  to proceed — has stood in the way of states’ accepting the funds. To date, only about half the states will Medicaid coverage on Jan. 1, 2014. A recent study by the Urban Institute found that an estimated 4.9 million people will remain uninsured because of the states that have decided against the expansion. Most of these states are in the South or the Mountain West, and half those people live in Florida, Georgia and Texas. (A recent Atlanta Journal-Constitution poll found that 60 percent of Georgians surveyed favored the expansion; Gov. Nathan Deal should listen to them.)  

The economic case for accepting the tens of billions of federal dollars on the table is clear: The money will stimulate jobs and economic growth. In a Sept. 27 New York Times op-ed, Kentucky Gov. Steve Beshear wrote that, according to PricewaterhouseCoopers, and the Urban Studies Institute, “expanding Medicaid would inject $15.6 billion into Kentucky’s economy over the next eight years” and create nearly 17,000 new jobs. “In short,” he wrote, “we couldn’t afford not to do it.” Hospitals also have an enormous amount at stake because their emergency rooms will continue to see uninsured patients when they are sicker and cost more to treat — shifting the costs to other payers in the system. Providing newly insured persons with the primary and preventive care that accompanies Medicaid coverage makes much more sense, since it will help prevent health problems from getting worse and more costly.

The moral case is even stronger. The poorest Americans will face a coverage gap come Jan. 1. Those above the designated threshold will be able to get tax credits and shop in the new health-insurance marketplaces. But in states that have not opted for Medicaid expansion, those below that threshold will have no coverage option.

Children, too, will benefit from states moving forward with Medicaid coverage for their parents, even though their eligibility levels won’t change. The vast majority of uninsured children — 70 percent — are eligible for Medicaid or CHIP but are not enrolled. If states extend the welcome mat to their parents, research clearly shows that these kids will be more likely to get enrolled. Indeed, the ACA requires that parents sign their children up for Medicaid before enrolling themselves.

When CHIP was passed in 1997, it took two years for all states to join the program, but they eventually did. The last holdout was Texas, led by then-governor George W. Bush. Let us hope that by 2016, all states have accepted the federal funding on the table for Medicaid and have moved forward to fulfill the promise of the Affordable Care Act for our most vulnerable citizens.

Opinions expressed here do not necessarily reflect those of Al Jazeera America.