Opting Out of Medicaid Expansion Will Leave Millions Uninsured

More than 5 million people will remain uninsured in the 26 states that chose not to expand Medicaid, according to an analysis by the Kaiser Family Foundation.

The Affordable Care Act initially included coverage for all adults below the poverty line through a national expansion of Medicaid, the government insurance program for very low-income people. But a Supreme Court ruling on health care reform said that states must be able to opt out of the Medicaid expansion if they wished.

Most states had strict rules about who qualified for the insurance program and excluded childless adults, primarily extending coverage to children, parents with dependent children, the disabled and poor senior citizens. Thirty percent of poor, non-elderly adults had Medicaid in 2012, compared to 70 percent of children. Overall, poor adults were more than twice as likely to be uninsured (42 percent) compared to the national average (18 percent).

The 26 states that opted out of the Medicaid expansion will see many poor people fall into a gap, one where they aren’t covered by the government insurance program because of strict eligibility requirements and don’t qualify for assistance purchasing insurance on state exchanges. Because the Affordable Care Act intended to offer Medicaid to poor adults, those who make less than the poverty line aren’t eligible for the subsidies that go to people with more income.

More than half of those who fall into this coverage gap live in Texas, Florida, Georgia, North Carolina and Ohio.

California, one of the states that embraced the Medicaid expansion, has rolled out benefits for childless adults early, starting in 2010. California has already enrolled 500,000 childless adults in a program called the low-income health plan, according to an analysis by the UC Berkeley Labor Center. The report also noted that an additional 1.4 million Californians will be newly eligible for Medi-Cal (as Medicaid is called in California) in 2014.

Most of those enrolled in the low-income health plan will be rolled over to Medi-Cal in 2014 and the remainder will be eligible to purchase subsidized insurance on the state’s exchange, Covered California.

Even in California, though, a significant number of people – an estimated 3 to 4 million – are expected to remain uninsured five years after the Affordable Care Act’s signature benefits — the exchange and the expansion of Medi-Cal — take effect on Jan. 1. Most of the remaining uninsured will either be unable to find an affordable insurance option or will be undocumented and not eligible to purchase insurance on the exchange or for the expansion of Medi-Cal.

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