By Suzanne Wikle 

In August 2020, Missouri voters approved a constitutional amendment to expand Medicaid to provide health insurance for the 230,000 Missourians in the coverage gap, effective July 1, 2021. Denying the will of the voters, in May the Missouri legislature refused to fund the expansion and then the governor withdrew the state’s expansion plan from the Centers for Medicaid and Medicare Services (CMS).

The blatant and unconstitutional disregard the legislature showed toward Missouri voters is just the latest example of state legislatures denying affordable health care to their constituents. Nearly a decade after the Supreme Court made Medicaid expansion under the Affordable Care Act (ACA) a state option rather than a national guarantee, 12 states – now 13 counting Missouri – continue to refuse to expand Medicaid.

The ACA was designed to provide near-universal coverage by using Medicaid to cover people earning less than 138 percent of the poverty level and provide tax credits (to those up to 400 percent of poverty) for private insurance through the ACA’s Marketplace for people earning too much to qualify for Medicaid but who don’t have affordable employer coverage. The Supreme Court’s decision to allow states to opt out of the ACA’s Medicaid expansion left millions of people with low incomes ineligible for any affordable coverage (creating the so-called “coverage gap”).

Due to the history of systemic racism in America that has led to inequitable education and employment opportunities for people of color, the coverage gap is more likely to leave Black and Latinx people without affordable health care. This is because Black and Latinx people are more likely to work in jobs that don’t offer health insurance and don’t pay enough to allow them to afford private insurance. Systemic racism (including voter suppression and gerrymandering) has also led to state legislatures, particularly in the South, being comprised of people who don’t truly reflect the communities in the state, and therefore resist policies like Medicaid expansion that residents of the state overwhelmingly support.

It’s time for Congress to act where states will not. Despite the overwhelming evidence that Medicaid expansion improves health, decreases health disparities, and is an economic win for states, several states are still refusing to do what’s in the best interest of their communities. Missouri is the most recent egregious example because the legislature is trying to reverse the outcome of a ballot initiative, but Missouri is not the only state where people continue to lack access to affordable health care simply because of where they live.

Without federal action at least 2.2 million people nationwide will continue to be denied access to affordable health insurance because of where they live and because of the pernicious and lasting harm that racism inflicts on all of us.  Nearly all are in the South, and Black and Hispanic people disproportionately fall into the coverage gap. No incentive has yet convinced the remaining states to expand Medicaid, and it’s hard to envision an incentive that could be more enticing than what’s already been offered, as described below.

When the ACA went into effect, states received 100 percent federal dollars to pay for Medicaid expansion, and the federal government continues to pay 90 percent of expansion costs. This year states were offered hundreds of millions of additional dollars to expand Medicaid, but we haven’t seen another state expand. For years state legislators across the holdout states claimed the cost of expansion was prohibitive. Now that there’s more than ample money on the table, it’s clear – as many suspected – that money was never really the core of the resistance. Rather, it’s an ideological battle rooted in racism and antagonism toward anyone who isn’t fortunate enough to be offered health insurance through an employer.

Closing the coverage gap is about race and health equity. CLASP believes everyone should have affordable and accessible health care. Eliminating the coverage gap is a critical step toward this end. CLASP encourages the new leadership in the Biden-Harris Administration to provide a solution that will finally end the coverage gap and take an important step toward reducing health inequities.