Why Should Remaining Holdout States Expand Medicaid?

April is Medicaid Awareness Month, and the Republican lawmakers in the states that have not yet expanded Medicaid now have even more reason to do so. In addition to providing affordable coverage options for millions of uninsured Americans through the Affordable Care Act, the American Rescue Plan provides robust financial incentives for the 14 states that have not implemented Medicaid expansion. The new offer is too good for holdout states to turn down: In addition to covering 90 percent of the costs for the expansion population, the federal government will chip in an extra 5 percent for the traditional Medicaid population for two years. This translates to billions in additional dollars for the states. 

Despite the overwhelming benefits of Medicaid expansion, Republicans have spent years undermining the ACA and its expansion of Medicaid at every turn, blocking millions from coverage. Yet the program has become increasingly popular among conservative voters. In 2020, the country saw voters in two deeply conservative states, Oklahoma and Missouri, approve expansion. 75 percent of Americans have a favorable view toward the Medicaid program, and 61 percent of Americans in non-expansion states favor expansion. 

Research confirms that Medicaid expansion increases access to care, improves financial security, and leads to better health outcomes. Medicaid expansion has played a vital role in reducing racial disparities in health care access and has served as a critical safety net during the pandemic. An estimated four million uninsured adults — including 640,000 frontline workers, 500,000 people with disabilities, and 926,000 older adults aged 50 to 64 — could gain coverage if the remaining holdout states adopted expansion. Importantly, people of color make up nearly 60 percent of this group. In total, more than 6 million people could enroll in Medicaid if the remaining states implemented expansion.

*Voters in Missouri and Oklahoma have approved expansion in 2020, but these states have not yet implemented the program. Both states are eligible for enhanced funding under the American Rescue Plan. 

Medicaid Expansion Saves Lives. 

• Reduced mortality in adults by nearly 4 percent. A study published in the Journal of Health Economics found that Medicaid expansion reduced mortality in people aged 20 to 64 by 3.6 percent.
• Saved the lives of at least 19,200 older adults. According to the Center on Budget and Policy Priorities, Medicaid expansion saved the lives of 19,200 older adults aged 55 to 64 between 2014 and 2017. At the same time,15,600 older adults died prematurely as a result of their states’ decision not to expand the program. 
• Reduced cancer and heart-related deaths. While scientific advancements have led to improved prognosis for many diseases, Medicaid expansion increased access to care and, subsequently, improved disease outcomes. Between 1999 and 2017, cancer deaths dropped more in states that expanded Medicaid coverage under the ACA than in states that rejected expansion. Additionally, research presented at the American Heart Association’s Scientific Sessions found that Medicaid expansion was tied to fewer heart-related deaths. 
• Reduced infant & maternal mortality. Multiple studies draw the connection between Medicaid expansion and reduced infant and maternal mortality rates. One study published in the American Journal of Public Health found the gains made in reducing infant mortality was more than 50 percent greater in states that expanded Medicaid, compared to those that did not. 

Medicaid Expansion Leads To Better Health Outcomes.

• Improved health of enrollees. A survey of more than 3,000 Michigan Medicaid expansion enrollees found that the percentage of those reporting poor health days decreased over time, with the biggest decreases among Black and low-income patients. Similar research showed that patients in expansion states were less likely to report declining physical and mental health. Additionally, one study shows that tobacco users were more likely to quit in Medicaid expansion states.
• Improved infant & maternal health. The uninsured rate for women of childbearing age in non-expansion states is nearly double than in states that expanded their programs (16 vs. 9 percent). Research from the Georgetown Center for Children and Families found that Medicaid expansion has helped fill gaps in maternal health coverage, leading to healthier mothers and babies. It also helps new mothers maintain access to coverage and important postpartum care after giving birth. 

Medicaid Expansion Helps People Access Treatment & Preventive Care. 

• Increased access to preventative care, cancer screenings and disease-specific treatment. Medicaid expansion has helped patients access preventative care, including colon cancer screenings. Expansion also increased patient access to kidney transplants and made diabetes medication more affordable for low-income patients. The program was also tied to earlier diagnosis of colorectal cancer and reducing diabetes-related amputations.
• Improved access to primary care & family planning. Two studies from Michigan showed that Medicaid expansion doubled low-income patients’ access to primary care, and that enrollees experienced improved access to birth control and family planning. 
• Increased access to substance abuse treatment. Study after study has shown that Medicaid expansion has increased access to addiction treatment and mental health services. And new research shows that as many as 8,132 people were saved from fatal opioid overdoses as a direct result of Medicaid expansion.
• Increased coverage for children. When parents have health insurance, their children are more likely to be insured. A study in Health Affairs found that 710,000 children gained public coverage as a result of their parents enrolling in Medicaid between 2013 and 2015. 

Medicaid Expansion Reduces Racial Disparities In Health Care. 

• Reduced racial disparities in health insurance coverage and access to care. The ACA led to historic reductions in racial disparities in access to health care, but racial gaps in insurance coverage narrowed the most in states that adopted Medicaid expansion. Per the Commonwealth Fund: “Coverage disparities in expansion states narrowed the most over the period. The black–white coverage gap in those states dropped from 8.4 percentage points to 3.7 points, while the difference between Hispanic and white uninsured rates fell from 23.2 points to 12.7 points.” 
• Reduced disparities in infant and maternal health. One study found that reductions in maternal mortality in expansion states were concentrated among Black mothers, “suggesting that expansion could be contributing to decreasing racial disparities in maternal mortality.” Expansion has also been tied to improving health outcomes for black babies, significantly reducing racial disparities in low birth weight and premature birth. 
• Better access to care. Medicaid expansion reduced racial disparities in cancer care and resulted in earlier diagnosis and treatment for Black patients. According to the Center for American Progress, Black women were more likely to receive care because of the ACA.

Medicaid Expansion Improves Financial Security. 

• Reduced income inequality. A January 2021 study from Health Affairs found that the ACA helped reduce income inequality across the board, but much more dramatically in Medicaid expansion states. The bottom 10th percentile of earners In Medicaid expansion states saw a 22.4 percent boost in their income, compared to 11.4 percent in non-expansion states. A study in Health Affairs found that Medicaid Expansion also caused a “significant” reduction in poverty. 
• Reduced medical debt. The chance of accruing medical debt is 20 percent lower in states that have expanded Medicaid. Additionally, a 2018 National Bureau of Economic Research analysis found that Medicaid expansion led to a nearly $6 billion decline in unpaid medical bills and to higher credit scores. 
• Boosted employment. Reports from Ohio and Michigan found that Medicaid expansion helped enrollees hold down jobs and look for work. Relatedly, a study from the University of Kansas found that people with disabilities are much more likely to be employed in states that have expanded Medicaid coverage. Additionally, the number of people who report not working because of a disability declined in expansion states.  

Medicaid Expansion Is A Lifeline For Rural Hospitals.

• Lowered uncompensated care costs. Medicaid expansion has saved hospitals an average of $6.4 million In uncompensated care costs. In 2017, uncompensated care costs comprised 6 percent of total expenses for hospitals in states that rejected Medicaid expansion—double the amount for hospitals located in expansion states. Additional research shows that expansion states saw a reduction in preventable hospitalizations and lower hospital costs. 
• Increased rural hospital profits. More than 130 rural hospitals have closed since 2010. The vast majority closed in states that had not expanded Medicaid at the time of the hospital closure. Research confirms that expansion increased rural and safety-net hospital profit margins. Rural hospitals in Medicaid expansion states are 62 percent less likely to close, and 75 percent of vulnerable rural hospitals are in non-expansion states. 
• Provides coverage for rural Americans. Thanks to the ACA, nearly 1.7 million rural Americans gained Medicaid coverage. The uninsured rate for low-income adults dropped from 35 percent to 16 percent in rural areas and small towns in states that expanded Medicaid.