Medicaid Expansion: Closing the Coverage Gap

Gilda Geist
CAP English 9
Blue Group
4/1/15

Healthcare is a basic human need. All humans need someone or something to care for
their health. Whether its a stomach bug that might keep someone home from work, a mental
illness that could disrupt someones daily life, or a chronic disease, everyone deserves to be
treated for it. Since the Patient Protection and Affordable Care Act was enacted on March 23rd,
2010 (Patient Protection and Affordable Care Act), health care in the United States has improved
drastically. Because some states opt not to expand Medicaid, however, some people are still not
eligible for the health care that they need. This is because these people fall into the coverage gap,
meaning that their income is too high to be eligible for Medicaid, but too low to get Marketplace
premium tax credits. Because of Federal funding, the solution to this problem is simple Medicaid expansion. With expanded Medicaid, people who fall into the coverage gap receive
health care. 28 states and DC have taken advantage of the government subsidies and expanded
Medicaid. The remaining states, however, have turned down the funding and do not provide
Medicaid to all of their residents, leaving about 5* million people without healthcare. 90% of
uninsured adults that could have been reached by Medicaid are not eligible due to states
choosing not to expand (kff.org). All states must expand Medicaid because it has successfully
provided healthcare to people in states that have implemented it already, it can help states save
money over time, and it will close the coverage gap, giving nearly everyone in the United States
access to health care.
Although Medicaid is currently providing millions of people with coverage, it has its
limits to who it affects. The Federal government offers subsidies to every state in the country, as
well as the District of Columbia. A Supreme Court ruling in June of 2012 gave states the right to
refuse these subsidies and opt out of expanding Medicaid (healthaffair.org). The results of this
ruling have left millions of people in the coverage gap, without healthcare. Being without health

care can mean different things for different people. For some, it means having to go to the
emergency room every time they get sick or injured because they cannot afford a regular doctor.
For others, it means that they have to save up to be able to go to the doctor, which gives their
ailments time to become more severe. It could also mean not being able to afford the medication
that they need to stay mentally or physically healthy. Medicaid expansion can eradicate these
issues. If states do not expand Medicaid, however, then the people in the coverage gap will
continue to struggle with every malady or injury that crosses their path.
There are several healthcare necessities that people in the coverage gap do not have
access to. First of all, many people who cannot afford health care but suffer from mental illnesses
go untreated. About 25% of Americans do not receive adequate mental health services (apa.org).
Secondly, for several chronic diseases, physical and mental, many people require health homes
(pcpcc.org). This program is working to be implemented nationwide under the Affordable Care
Act section 2703. It gives people with chronic disorders access to specialized health care.
Eligibility for this program, however, varies depending on the extent of Medicaid in any given
state (medicaid.gov). Additionally, while 88% of adults on Medicaid could afford prescription
drugs, only 79% of uninsured adults could (kff.org). People in the coverage gap often lack access
to home health care, medication, and other medical assistance that they would have if Medicaid
expanded.
States that have implemented Medicaid expansion are already showing positive results.
First of all, in states that have expanded Medicaid, most adults at or below 138% of the Federal
Poverty Level receive healthcare, and 0% of the states population fall in the coverage gap
(healthaffair.com) (kff.org). Also, after 26 states plus DC had expanded Medicaid, 6 million
people had gained coverage. Secondly, in comparison to those with health care, the people who

fall in the coverage gap lack many medical needs. For example, 53% of uninsured nonelderly
adults have no regular doctor that they go to, while only 10% of those with Medicaid do not have
regular doctors (kff.org). Also, 30% of uninsured nonelderly adults are without health care
because they cannot afford it, while only 11% of people with Medicaid have this issue (kff.org).
Expanding Medicaid has made access to health care easier and more affordable for millions of
people, and therefore should be implemented nationwide.
There are about 5 million people nationwide who fall into the coverage gap, many of
whom are individuals and families that fall between 50% and 100% of the Federal Poverty Level
(kff.org). While these people often cannot afford health care, people who have a higher salary
than them are receiving subsidies to pay for their insurance. First of all, since the people from
50% to 100% of the Federal Poverty Line are generally low-wage workers, they usually cannot
afford coverage, even when employer-sponsored health insurance is available. 38.2% of
uninsured nonelderly adults are uninsured because they cannot afford insurance. Parents in
families above 46% and just below 100% of the Federal Poverty Level fall into the coverage gap
(kff.org). If the parents encounter a health issue and cannot receive medical attention, their
condition could worsen, keeping them home from work and causing their familys financial
status to decline further. Secondly, people who live over 100% of the Federal Poverty Level
receive Marketplace subsidies, making it easier for them to afford insurance that they were likely
already able to pay for. Meanwhile, families of four making less than $23,850 per year may not
be eligible for Marketplace subsidies or Medicaid, meaning that they fall into the coverage gap
(healthcare.gov). Money that is going to people living up to 400% above the Federal Poverty
Level could be going to low-income people living in the coverage gap with little or no access to
health care.

While many of the people who fall into the coverage gap fall between 50% and 100% of
the Federal Poverty Level, there are others who suffer due to the coverage gap, with different
financial situations. Childless adults and unemployed individuals often remain uninsured. First of
all, 76% of adults in the coverage gap are childless (kff.org). Medicaid generally does not offer
healthcare to childless adults, while expanded Medicaid does. Secondly, 28.6% of uninsured
nonelderly adults are uninsured due to a loss of a job. This is the second highest reason for
nonelderly adults to be uninsured. The highest reason is that healthcare is too expensive. It is
likely that there is an overlap here. If an adult is unemployed, they probably cannot afford health
care. For this reason, unemployed adults in the coverage gap likely in need of Medicaid more
than some other groups of people, such as those living significantly above the Federal Poverty
Level. An individual making less than $11,670 in a state with unexpanded Medicaid will likely
not be eligible for Marketplace savings, therefore providing low-income adults with no subsidies
(healthcare.gov). Medicaid expansion, however, provides childless and/or low income adults
with health care.
Not only would expanding Medicaid be better for individuals, but it would also be better
for states as a whole. Many states opt not to adopt expanded Medicaid due to cost. The
government, however, subsidizes 100% of the money going to expanded Medicaid for the first 3
years that it is implemented. After 2020, the government will still fund expanded Medicaid with
90% subsidies (money.cnn.com). Additionally, states would actually lose money by not
expanding Medicaid. For example, the first 14 states to turn down the subsidies for Medicaid
expansion will lose an estimated total of $8.4 billion (money.cnn.com). These states could also
lose another $1 billion by 2016 due to uncompensated care (rand.org). Uncompensated care
usually occurs when people are uninsured and their only option is to seek medical attention

somewhere that provides charity care (apprisehealthinsights.com). For example, someone

without health care who had pneumonia might go to the emergency room, since it is required that
all patients of the emergency room be treated, regardless of financial status. The state, however,
has to then pay for this trip to the emergency room, since the patient was unable to pay
themselves. If states expanded Medicaid, people who use charity care would have regular
doctors to go to when they get sick, and the states would not have to fund uncompensated care.
Expanding Medicaid would benefit states because it would save them money over time.
Medicaid expansion should be mandated nationwide because it would, as it has already
done in other states, provide healthcare to people in the coverage gap who cannot afford it on
their own. Over half of the nation has expanded Medicaid already. In these areas of the United
States, there are no people who fall into the coverage gap, and people have access to mental and
physical health care. Those who could not normally afford regular doctors, prescription
medication, and other health necessities, now can. Uncompensated care does not occur as often,
and government subsidies are used to cover the cost of providing healthcare to the states
residents. As a result, these states save money. If Medicaid is not expanded throughout the
United States, however, the 5 million people in the coverage gap will continue to go without
access to sufficient health care, just as they do today.

Works Cited
"ACA Section 2703 Health Homes." Patient-Centered Primary Care Collaborative. N.p., 2014.
Web. 1 Apr. 2015. <https://www.pcpcc.org/initiative/aca-section-2703-health-homes>.
"Access to Mental Health Care." American Psychological Association. APA, 2015. Web. 11 Mar.
2015. <http://www.apa.org/health-reform/access-mental-health.html>.
"Access to Mental Health Care." Office of Adolescent Health. OAH, 27 Feb. 2015. Web. 11 Mar.
2015. <http://www.hhs.gov/ash/oah/adolescent-health-topics/mental-health/accessmental-health.html>.
"Affordable Care Act." Medicaid. N.p., n.d. Web. 1 Apr. 2015.
<http://medicaid.gov/affordablecareact/affordable-care-act.html>.
"Health Homes." Medicaid. Medicaid, n.d. Web. 11 Mar. 2015.
<http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-TermServices-and-Supports/Integrating-Care/Health-Homes/Health-Homes.html>.
"How Will the Uninsured Fare under the Affordable Care Act?" The Henry J. Kaiser Family
Foundation. Wordpress, 7 Apr. 2014. Web. 1 Apr. 2015. <http://kff.org/healthreform/fact-sheet/how-will-the-uninsured-fare-under-the-affordable-care-act/>.
"Implementing the ACAs Medicaid-Related Health Reform Provisions after the Supreme
Courts Decision." The Henry J. Kaiser Family Foundation. Wordpress, 1 Aug. 2012.
Web. 1 Apr. 2015. <http://kff.org/health-reform/issue-brief/implementing-the-acasmedicaid-related-health-reform/>.
Leonard, Kimberly. "Under Obamacare, Mental Health Lacking." U.S. News and World Report.
U.S. News and World Report, 29 Oct. 2014. Web. 11 Mar. 2015.

<http://www.usnews.com/news/articles/2014/10/29/obamacare-hasnt-propelled-mentalhealth-treatment>.
Luhby, Tami. "CNN Money." CNN Money. Cable News Network, 1 July 2013. Web. 1 Apr. 2015.
<http://money.cnn.com/2013/07/01/news/economy/medicaid-expansion-states/?iid=EL>.
McCanne, Donn. "5.2 Million People Fall into the ACA Coverage Gap." Physicians for a
National Health Program. N.p., 17 Oct. 2013. Web. 1 Apr. 2015.
<http://pnhp.org/blog/2013/10/17/5-2-million-people-fall-into-aca-coverage-gap/>.
"Medicaid Expansion and What It Means for You." Health Care. USA.gov, n.d. Web. 11 Mar.
2015. <https://www.healthcare.gov/medicaid-chip/medicaid-expansion-and-you/>.
Patient Protection and Affordable Care Act. 1 USC. Print.
Prince, Carter C., and Christine Eibner. "For States That Opt out of Medicaid Expansion." RAND
Corporation. N.p., 6 June 2013. Web. 1 Apr. 2015.
<http://www.rand.org/pubs/external_publications/EP50279.html>.
"Uncompensated Care." Apprise Health Insights. Oregon Association of Hospitals & Health
Systems, 2015. Web. 1 Apr. 2015. <http://apprisehealthinsights.com/public-reports/ucc/>.
Weaver, Christopher. "Millions Trapped in Health Law Coverage Gap." Wall Street Journal.
N.p., 18 Feb. 2014. Web. 1 Apr. 2015.
<http://www.wsj.com/articles/SB10001424052702304851104579363621009670740>.

Annotated Bibliography

"ACA Section 2703 Health Homes." Patient-Centered Primary Care Collaborative. N.p., 2014.
Web. 1 Apr. 2015. <https://www.pcpcc.org/initiative/aca-section-2703-health-homes>.
This source provided information on the importance of health homes. It also had information
directly from the Affordable Care Act.
"Access to Mental Health Care." American Psychological Association. APA, 2015. Web. 11 Mar.
2015. <http://www.apa.org/health-reform/access-mental-health.html>.
This source provided information on how different people have different levels of access to
health care. It showed specific information on what people needed in order to access health care.
"Access to Mental Health Care." Office of Adolescent Health. OAH, 27 Feb. 2015. Web. 11 Mar.
2015. <http://www.hhs.gov/ash/oah/adolescent-health-topics/mental-health/accessmental-health.html>.
The sources provided information on how different group of people had different levels of access
to mental health care. It also showed the importance on mental health care and emphasizes that
not enough people have access to it.
"Affordable Care Act." Medicaid. N.p., n.d. Web. 1 Apr. 2015.
<http://medicaid.gov/affordablecareact/affordable-care-act.html>.
This source describes the purpose and effect of the Affordable Care Act. It is surprisingly
unbiased, because it shows the negative impacts of unexpanded Medicaid well, considering that
it is Medicaids website.
Green, John. Applying for Health Insurance: Then and Now. YouTube. N.p., 8 Oct. 2013. Web.
15 Mar. 2015. <https://www.youtube.com/watch?v=ql9RVy6FWkg>.
This video shows how health care reforms impacted how easy or difficult it was for different
people to get health care.

Green, John. Bigger Pizzas: A Capitalist Case for Health Care Reform. YouTube. N.p., 3 Sept.
2013. Web. 15 Mar. 2015. <https://www.youtube.com/watch?v=R7LF5Vj2n64>.
This video provides a capitalist perspective of health care. It uses analogies and casual language
to explain the issue with todays healthcare and what causes those issues to arise.
Green, John. Why Are American Health Care Costs so High? YouTube. N.p., 20 Aug. 2013. Web.
15 Mar. 2015. <https://www.youtube.com/watch?v=qSjGouBmo0M>.
This video explains different explanations for why health care costs are so high and how that
affects different groups of people based on economic status.
"Health Homes." Medicaid. Medicaid, n.d. Web. 11 Mar. 2015.
<http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-TermServices-and-Supports/Integrating-Care/Health-Homes/Health-Homes.html>.
This source provides information on the significance of health homes. It also shows that in places
that do not expand Medicaid, not everyone can get health homes, and why this is an issue.
"How Will the Uninsured Fare under the Affordable Care Act?" The Henry J. Kaiser Family
Foundation. Wordpress, 7 Apr. 2014. Web. 1 Apr. 2015. <http://kff.org/healthreform/fact-sheet/how-will-the-uninsured-fare-under-the-affordable-care-act/>.
This source provides many statistics and graphs that show the negative effects of being uninsured
in regards to health care.
"Implementing the ACAs Medicaid-Related Health Reform Provisions after the Supreme
Courts Decision." The Henry J. Kaiser Family Foundation. Wordpress, 1 Aug. 2012.
Web. 1 Apr. 2015. <http://kff.org/health-reform/issue-brief/implementing-the-acasmedicaid-related-health-reform/>.

This source shows how expanding Medicaid is necessary through the use of statistics and graphs
that were good to cite in the paper.
"Joint CMCS and SAMHSA Informational Bulletin." Medicaid. Medicaid, 7 May 2013. Web. 11
Mar. 2015. <http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-05-072013.pdf>.
This source provides information on different health care programs that were working on being
implemented, such as health homes. It also talked briefly about access to these programs.
Leonard, Kimberly. "Under Obamacare, Mental Health Lacking." U.S. News and World Report.
U.S. News and World Report, 29 Oct. 2014. Web. 11 Mar. 2015.
<http://www.usnews.com/news/articles/2014/10/29/obamacare-hasnt-propelled-mentalhealth-treatment>.
This source showed how unexpanded Medicaid was doing very little to help provide adequate
mental health care in the US. It also provided some statistics showing the number of people that
were being affected by this lack of productivity under the subject of mental health.
Luhby, Tami. "CNN Money." CNN Money. Cable News Network, 1 July 2013. Web. 1 Apr. 2015.
<http://money.cnn.com/2013/07/01/news/economy/medicaid-expansion-states/?iid=EL>.
This source provided a lot of information on the coverage gap. It also showed how states that did
not expand Medicaid were actually losing money. It also linked to some other good sources.
McCanne, Donn. "5.2 Million People Fall into the ACA Coverage Gap." Physicians for a
National Health Program. N.p., 17 Oct. 2013. Web. 1 Apr. 2015.
<http://pnhp.org/blog/2013/10/17/5-2-million-people-fall-into-aca-coverage-gap/>.
This source provided information on the coverage gap and the characteristics of people who were
in it. It also had several good statistics.

"Medicaid Expansion and What It Means for You." Health Care. USA.gov, n.d. Web. 11 Mar.
2015. <https://www.healthcare.gov/medicaid-chip/medicaid-expansion-and-you/>.
This source had very specific statistics showing what income was eligible for Medicaid and
Marketplace subsidies. These proved to be very important in some of the papers strongest
arguments.
"ObamaCare Medicaid Expansion." ObamaCare Facts. N.p., n.d. Web. 11 Mar. 2015.
<http://obamacarefacts.com/obamacares-medicaid-expansion/>.
This source provided some more obscure information on how Medicaid was addressing mental
health. This was useful because it was a bit more difficult to find such information.
Patient Protection and Affordable Care Act. 1 USC. Print.
This source was the law that enacted Medicaid and described its intentions and its purpose. It
was very useful to cite because it is very reliable.
Pratt, Laura A., Debra J. Brody, and Qiuping Gu. "Antidepressant Use in Persons Aged 12 and
Over: United States, 20052008." Centers for Disease Control and Prevention. CDC,
Oct. 2011. Web. 11 Mar. 2015. <http://www.cdc.gov/nchs/data/databriefs/db76.pdf>.
This source showed the number of people in the US who were on antidepressants, emphasizing
how large the number was. This was useful because it emphasized the importance of addressing
mental health when looking at health care.
Prince, Carter C., and Christine Eibner. "For States That Opt out of Medicaid Expansion." RAND
Corporation. N.p., 6 June 2013. Web. 1 Apr. 2015.
<http://www.rand.org/pubs/external_publications/EP50279.html>.

This source showed the negative impact of opting out of Medicaid expansion for states
economies. This was useful because it created a new argument in the paper that appealed to an
audience looking for a logos argument.
"Uncompensated Care." Apprise Health Insights. Oregon Association of Hospitals & Health
Systems, 2015. Web. 1 Apr. 2015. <http://apprisehealthinsights.com/public-reports/ucc/>.
This source provided a definition of uncompensated care and explained why it can be an issue
for states. This was also useful in the argument mentioned above.
Weaver, Christopher. "Millions Trapped in Health Law Coverage Gap." Wall Street Journal.
N.p., 18 Feb. 2014. Web. 1 Apr. 2015.
<http://www.wsj.com/articles/SB10001424052702304851104579363621009670740>.
This source was used in attempt to corroborate the controversial statistic of how many people
were in the coverage gap.