Significant Gains for Medicaid Expansion, Yet Inequities Remain

By Suzanne Wikle

Voters in Utah, Nebraska, and Idaho all gave a resounding “yes” to Medicaid expansion when they went to the polls for the 2018 midterms. When these expansions are implemented, over 300,000 additional people—mostly those working in low-wage jobs that don’t offer health insurance benefits—will be eligible for affordable health insurance through Medicaid. 

Having affordable health care brings access to doctors and medications while also eliminating a common cause of financial ruin and bankruptcy among low-income families. The midterms also brought a new governor in Maine who will implement the 2017 ballot initiative to expand Medicaid that the current governor refused to do. And 2018’s election also signals improved political climates for expansion in Kansas, Wisconsin, and North Carolina. 

With the exception of North Carolina on the list of states moving forward or better poised to do so, all of the states are northern or western states. Southern states have largely chosen not to expand Medicaid as intended by the Affordable Care Act (ACA). As a result, people in the South who remain in the coverage gap continue to experience inequities in access to affordable health care. 

A study earlier this year by the Kaiser Family Foundation showed that 89 percent of people in the Medicaid coverage gap live in the South and that nearly half of everyone in the coverage gap live in just two states—Texas and Florida. Georgia has the third highest number of people who are in the coverage gap. Among these three states, more than 2.3 million people would be eligible for Medicaid under expansion. 

Across the states in the South that have not expanded Medicaid those who stand to gain affordable health insurance through expansion are disproportionately people of color. In Texas, 74 percent of the population in the coverage gap is people of color, primarily black. In Georgia this number is 60 percent, and in Florida it is 47 percent. In fact, across all non-expansion states in the South for which the Kaiser report provides this breakdown, people of color are disproportionately represented in the coverage gap. 

The report says, “The racial and ethnic composition of the population that falls into the coverage gap indicates that state decisions not to expand their programs disproportionately affect people of color, particularly Black Americans. As a result, state decisions about whether to expand Medicaid have implications for efforts to address health disparities in health coverage, access, and outcomes among people of color.” 

This last point remains true following the success at the ballot box on November 6. Although Utah, Idaho, and Nebraska all made progress, the continued lack of action to expand Medicaid across all states—particularly many in the South—leaves in place significant disparities on access to care. Access to Medicaid continues to depend on the state in which you live, with low-income people in the South—and particularly people of color—continuing to be left behind and not benefitting from the many benefits of Medicaid expansion. Ultimately this disparity between expansion states and non-expansion states stands to further exacerbate health disparities due to race, including decreased life expectancy for people of color. 

As we celebrate the wins at the ballot box for Medicaid expansion, we must simultaneously continue working to expand in all states in order to ensure that everyone has access to affordable health insurance.