The decision by so many states not to extend health care coverage will be devastating to those left behind. For them, the promise of universal care -- delayed already for decades -- will still be hollow.
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With all eyes on the roll-out of the online exchanges (also called marketplaces) set up by the Affordable Care Act (ACA), too little attention has been given to those who could get coverage through Medicaid expansion, if only states would adopt it. As it stands now, an estimated 21 million people who would have enrolled by 2022 will not get the health care they need because they live in one of the 25 states that rejected the Medicaid expansion funded by the new law. The decision by so many states not to extend health care coverage will be devastating to those left behind. For them, the promise of universal care -- delayed already for decades -- will still be hollow.

A majority of those will be women. As of now, women are two-thirds of adult Medicaid beneficiaries because they are more likely to be poor and fall into the existing categories of covered individuals -- those who are pregnant, the parent of a dependent child, over 65, or have a disability. Since women live longer, they are more likely to need long-term care (which is not covered by Medicare). Nearly half of all births in the U.S. are covered by Medicaid. Medicaid significantly improves health outcomes for both mothers and infants, providing routine prenatal as well as neonatal intensive care and ensuring access to family planning services.

Although a federal program, Medicaid is operated by the states. Until now each state has had its own rules on eligibility and level of benefits set by federal regulations. These rules have resulted in dramatically uneven coverage across the country. But under the ACA, the categories will be eliminated and all individuals below 138 percent of the federal poverty level will be covered if states adopt Medicaid expansion. Those criteria are far more generous than most current state programs. The federal government has offered to pay for the expansion for three years, after which it would pay a decreasing proportion of the cost, leveling out at 90 percent of the total by 2020. After that, states would then pay only the remaining 10 percent. If Medicaid expanded to all states, just over half of uninsured women would qualify for Medicaid.

When the Supreme Court ruled last year that states could not be required to expand Medicaid and half of them then chose not to do so, the goal of universal coverage became impossible to achieve. Now it is expected that Medicaid enrollment will increase by only five million this year, leaving 6.4 million without coverage. The New York Times estimates that this failure of states to expand Medicaid "will leave out two-thirds of poor blacks and single mothers and more than half of the low-wage workers who do not have insurance, the very kinds of people that the program was intended to help," according to its own analysis of census data.

The consequences of not having health insurance are well-documented. Adults who lack care are significantly less likely to get essential preventive care and screenings. They are more likely to have chronic conditions that go untreated. They are more likely to have life-threatening conditions diagnosed at a late stage of development. They are more likely to use the emergency room, where costs are higher and treatment can come too late. Women suffer such consequences at higher rates because they are less likely than men to have existing insurance coverage.

And children without insurance are less likely to get well-child care, immunizations, and basic dental care. Without checkups, serious childhood health problems go undetected, and children with special health care needs don't get access to specialists. They are even more likely to miss school and their moms are most likely to be the ones having to stay home and care for them thus missing work or school.

The bottom line for children and adults without insurance is that they are more likely to die sooner. Nearly 45,000 people die prematurely -- that is they die from preventable deaths -- when they lack access to health care.

Expanding Medicaid is not only the right thing to do, it will save states money -- an estimated total of $10 billion over 2013-2022, compared to the impact of the ACA without the expansion. That's because of the costs of uncompensated care that states would bear without the injection of federal funds into state health care systems - doctors, hospitals, etc.

Achieving universal access to health care is a daunting task. It means finding the millions without access and enrolling them in the programs for which they are eligible. It means ensuring we have enough providers to care for the new patient population. It means keeping down medical costs that have spiraled upwards, controlling the cost of drugs, managing chronic conditions, and encouraging life-style changes that will cut down on conditions such as diabetes, heart disease, and lung cancer. It means addressing geographic differences in the availability of care and reducing racial disparities and barriers faced by historically marginalized communities. The Affordable Care Act was written to go hand-in-hand with the expansion of Medicaid, but with so many states opting out of that expansion, millions of women will still be left behind.

As a nation, we cannot proclaim our commitment to the worth of every individual while we maintain a health care system that leaves so many without coverage. We need a national commitment to ensuring that everyone gets the health care he or she needs. Wasn't that the goal of passing the Affordable Care Act in the first place? Expanding Medicaid is a practical and moral imperative, and we must all see to it that every state takes this step.

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