The Case for Medicaid Expansion

by Kunal Kanaparti | Spring 2019

The refusal of some states to comply with the Affordable Care Act's call for Medicaid expansion has created a massive health care coverage gap. Eliminating this gap is exigent, and the most efficient way to go about this is to amend the ACA so that the federal government defrays a larger portion of Medicaid expansion costs.

1. "Medicaid." Accessed April 01, 2019.

2. "Medicaid Expansion Definition." November 21, 2018. Accessed April 01, 2019.

Since its inception over half a century ago, Medicaid has proven a source of perennial controversy. The program provides healthcare coverage to millions of Americans who meet several qualifying criteria, including low-income or elderly adults, pregnant women, people with disabilities, and children. [1] While federal guidelines broadly delineate how Medicaid care should be provided, the process of determining of who qualifies lies within the purview of state governments; predictably, states vary widely on this.

The issue of Medicaid expansion became especially provocative following the enactment of the Affordable Care Act, which mandated an expansion of Medicaid eligibility to cover all Americans whose incomes were 138 percent the federal poverty level. As incentive, the federal government would defray all concomitant costs until 2016 and no lower than 90 percent of such costs by 2020. Two years later, however, the Supreme Court established that the federal government could not coerce states into expanding their coverage beyond providing incentive; as such, in spite of the ACA’s guidelines, fourteen US states remain steadfastly opposed to expanding their coverage, including Texas, North Carolina and Georgia. [2]

Such opponents to expansion have averred that, despite federal funding, expanding coverage would still place exorbitant fiscal strain on the states and convolute the already intricate process of providing Medicaid coverage. These states continue to subscribe to pre-ACA Medicaid guidelines: Only individuals fulfilling specific criteria such as those with disabilities or children qualify.

Unfortunately, this has created a health care coverage gap. To explain, when the ACA was written, premium subsidies were to be granted only to those whose incomes were between 100 and 400 percent of the federal poverty level; those below 100 percent, it was assumed, would receive care by dint of Medicaid’s expanded coverage and thus did not need to receive subsidies. Hence, Americans below 100 percent of the federal poverty level who fail to qualify for Medicaid under pre-ACA guidelines—e.g., able-bodied, without children, not elderly—are bereft of any form of health care. [3]

Resolving the coverage gap is arguably the most exigent health care task in the US today, and the most efficient way to achieve this is for all states to accept federal funding for Medicaid expansion. Upon accepting federal funding, for instance, Utah, Idaho and Nebraska are already projected to eliminate their combined coverage gap of 84,000 individuals entirely. The remaining fourteen states, however, have proven to be less tractable, and since its landmark case in 2012, the Supreme Court has given no indication of reneging on its decision: The federal government will have to rely wholly on increasing incentives to mollify the intractable states into accepting expansion. To this end, amending the ACA so that the federal government will defray a larger share of expansion costs, over a longer period of time, will decrease the financial strain opponents claim their states will incur.


[1] "Medicaid." Accessed April 01, 2019.

[2] "Medicaid Expansion Definition." November 21, 2018. Accessed April 01, 2019.

[3] "What Is the Medicaid 'coverage Gap' and Who Does It Affect?" December 12, 2018. Accessed April 01, 2019.

3. "What Is the Medicaid 'coverage Gap' and Who Does It Affect?" December 12, 2018. Accessed April 01, 2019.

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