Now is the time for the people of "non-expanding" states to appeal to and lead their lawmakers out of the convoluted ACA partisan landscape. It is time for the remaining 22 states to expand Medicaid - it just makes sense.
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States that have not expanded Medicaid are nonsensically denying millions of uninsured individuals health care coverage. To date, 28 states (and Washington D.C.) have elected to expand Medicaid, while the remainder have not. It is time for these remaining 22 states to make decisions about Americans' health that make sense.

Medicaid is a government insurance program that provides health-care services to Americans with low incomes and limited resources and is estimated to cover over 1 in 5 Americans. As part of the Affordable Care Act (ACA), Medicaid expansion was originally mandated in all states.

What exactly does expansion mean? Prior to the ACA, eligibility for Medicaid varied from state to state. The median income cutoff for eligibility for working parents was 61% of the federal poverty level (FPL). That translated into a four-person household qualifying if their income was less than approximately $14,500. In most states, non-elderly adults without children weren't even eligible for Medicaid coverage. Expansion would have provided coverage for all adults up to 138% of the FPL, an income of approximately $32,900 for a four-person household.

However, a Supreme Court ruling in 2012 altered the ACA so that states could choose, rather than be required, to expand Medicaid. Now, states not expanding Medicaid have chosen to deny coverage for over 6 million uninsured residents. Ironically, these states would stand to benefit the most from expansion.

Many of these twenty-two states, predominately clustered in the Southern United States, already have extremely strict eligibility criteria for Medicaid (a median of 49% the FPL, or $11,700 for a four-person household) when compared to states that are adopting expansion. In the South, over 8 in 10 uninsured individuals that would have received coverage with expansion live in states that have chosen not to. Furthermore, uninsured adults without children can't even qualify for Medicaid in these states.

How can leaders in states not expanding Medicaid justify their punitive inaction? They can't.

Critics maintain that Medicaid does not improve patients' health. A wealth of literature counters this claim. A report by the Institute of Medicine found that health insurance coverage was associated with better health outcomes. Medicaid coverage in particular has been shown to increase use of preventative and health services, detection of diabetes, lower rates of depression, and nearly eliminate catastrophic out-of-pocket medical expenses. A study from the Harvard School of Public Health found that states that expanded Medicaid to cover low-income adults had lower rates of death compared to states that did not expand. Medicaid is, in fact, good for health and offers financial protection to vulnerable populations.

The cost of Medicaid is also contentious. Governor Rick Perry, for example, has ardently opposed Medicaid expansion in Texas, a state in which 30% of the adult population is uninsured. He asserts that, "It would benefit no one in our state to see their taxes skyrocket and our economy crushed as our budget crumbled under the weight of oppressive Medicaid costs."

This is misguided. Perry fails to cite that by refusing expansion, Texas will forgo $65 billion in federal funding over ten years. This is far greater than the $5.6 billion state cost of expansion over the same period. Meanwhile, approximately 1.7 million Texans that could be insured with Medicaid remain uninsured.

The non-partisan Urban Institute estimates that the 22 "non-expanding" states will pass on $368 billion in federal funding over ten years, staggeringly greater than the estimated total cost of expansion ($27.7 billion) in these states. Simultaneously, hospitals will lose $167.8 billion in reimbursements. Medicaid spending has also been shown to promote job and income growth as well as state tax revenue. Thus, these states are blatantly abjuring the broad, positive economic implications of reducing the number of uninsured, increasing hospital revenues, and increasing state savings through Medicaid expansion.

The beneficial impact of Medicaid expansion on health and economies is lucid. Leaders in states that have not expanded Medicaid need to allow evidence-based policy to trump partisan politics. They are accountable for the millions of vulnerable, low-income uninsured individuals that could and should have health care coverage.

Now is the time for the people of "non-expanding" states to appeal to and lead their lawmakers out of the convoluted ACA partisan landscape. It is time for the remaining 22 states to expand Medicaid - it just makes sense.

The views expressed in this article are those of the author and do not necessarily represent the views of, and should not be attributed to, his affiliated institutions.

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