A Look at Coverage Eligibility in Medicaid Nonexpansion States

In states that chose not to expand Medicaid eligibility under the Affordable Care Act (ACA), residents with a median income of less than $800 a month are now ineligible for coverage assistance while those with more than $2000 a month are eligible for subsidies, according to a report from the Urban Institute.

There are 6.3 million uninsured adults who could have qualified for Medicaid had their states expanded coverage—instead they are ineligible. Another 5.9 million uninsured adults in these non-expansion states qualify for federal subsidies for private insurance.

“In states that have not expanded Medicaid, adults ineligible for insurance affordability programs because of nonexpansion tend, by definition, to have lower incomes than adults who qualify for federal ACA subsidies,” authors Stan Dorn, Matthew Buettgens, and Jay Dev wrote in the report. “The financial gap between these groups is larger than some might expect.”

In the states that expanded Medicaid, 68% of individuals who had been uninsured prior to the ACA now qualify for Medicaid, the Children’s Health Insurance Program, or subsidies for private plans. In nonexpansion states, only 44% are now eligible.

Access to ACA assistance in nonexpansion states varies along racial lines, the researchers found. While whites are more likely to be eligible than ineligible, blacks and Latinos are both more likely to be ineligible than they are to be eligible for assistance.

Just 28% of uninsured black adults qualify for assistance to pay for health coverage, while 43% are ineligible because of the choice not to expand Medicaid coverage. In comparison, just a third of whites are ineligible, while 36% qualify for assistance.

The authors were surprised to find that women were more likely than men to be ineligible for ACA assistance. In 2011 and 2012 more women than men received Medicaid, but the underlying income gap adversely affects women. In nonexpansion states, women between the ages of 18 to 65 years make up 59% of those with incomes under 100% of the federal poverty, which is the income range most affected by states’ decisions not to expand Medicaid eligibility.