In States Failing to Expand Medicaid, People of Color are Disproportionately Left Uninsured

By Lavanya Mohan

More than 45 million people in the U.S. are uninsured. If every state expanded Medicaid coverage as intended under the Affordable Care Act (ACA), almost 25.4 million1 would be eligible to enroll in Medicaid. However, the recent Supreme Court decision on the ACA has effectively made Medicaid expansion a state decision. So far, 23 states and the District of Columbia have elected to expand coverage on January 1, 2014.  Conversely, 21 states have declined to expand Medicaid with an additional six states that are on the fence.2 This means that fewer people will be able to obtain health insurance. A recent report further finds that low-income individuals of color will be disproportionately affected by state decisions on whether or not to expand Medicaid.

Among the 27 states that have not elected to expand Medicaid on January 1, more than 27.4 million people remain uninsured, of which about 14.7 million would be eligible for Medicaid if their states adopted the ACA Medicaid expansion. In the 21 states that have formally declined expansion, almost half of the uninsured residents are people of color. According to the Kaiser Family Foundation, “people of color make up the majority of uninsured individuals…in states moving forward and not moving forward with the Medicaid expansion.” Fifty-nine percent of African-Americans and 44 percent of Hispanics live in states that are not moving forward with Medicaid expansion, with African-Americans most at risk of coverage gaps.

Because population, race, and ethnicity vary across the country, the decisions of a few key states will have a major impact on access to health care. Texas, Florida, and Georgia have the largest number of uninsured people across all races and ethnicities. By declining to move forward with Medicaid expansion, these states will leave millions uninsured, with a disproportionate number being minority ethnic and racial groups. The good news is that people of color will benefit from Medicaid expansion in states like California and New York, which have a large share of uninsured African-Americans, Hispanics, and Asian and Pacific Islanders.  

State decisions on whether or not to expand Medicaid will have a huge impact on low-income people of all races and ethnicities. As we have discussed, Medicaid expansion reduces financial hardship caused by medical costs and/or debt for poor families and improves overall health outcomes. There are also major fiscal implications for states. Delaying expansion is costly because 100 percent federal funding for newly eligible Medicaid recipients only lasts through 2016, phasing down to a permanent 90 percent matching rate by 2020. CLASP urges holdout states to act quickly to provide millions of families access to healthcare coverage while taking advantage of full federal funding. 

Kaiser Family Foundation, The Impact of Current State Medicaid Expansion Decisions on Coverage by Race and Ethnicity, Appendix Table 1, July 2013,

 As there is no definitive deadline for Medicaid expansion, states can opt in at a later period. As of July 2013, while 21 states have decided to not expand Medicaid, six additional states are undecided. Debate is ongoing in these undecided states: some are weighing state budgets and some others are exploring alternative approaches to the ACA’s Medicaid expansion that may require waiver approval to privatize Medicaid expansion. Further, in some states, the Governor and legislature have not yet come to an agreement on Medicaid expansion. Updates on where the states stand can be found here.