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Expansion "Gap" Puts Coverage Off Limits to 10% of Remaining Uninsured

Mary K. Caffrey
Although nearly 15 million Americans have obtained health coverage under the ACA, another 15.7 million are eligible but do not have coverage.
Almost 15 million Americans have gained insurance coverage since Affordable Care Act (ACA) took full effect in January 2014, and another 15.7 million—or nearly half the remaining uninsured—are eligible, according to a new survey.

But for nearly 3.1 million people, coverage will likely remain off limits, because they live in states that have not expanded Medicaid and remain in the “coverage gap.” Many of these households earn too much for traditional Medicaid and too little to access subsidies available through the federal Marketplace.

Findings from a survey of the Kaiser Family Foundation (KFF) on the eve of the third wave of open enrollment under the ACA show how many Americans have become insured under the most sweeping changes to the nation’s healthcare laws since the advent of Medicare and Medicaid 50 years ago. But the survey found that much remains to be done to educate consumers who remain unaware or unsure about the provisions of the law, or who still find coverage unaffordable, even with subsidies.

A survey taken in late 2013 by KFF found that 47 million Americans lacked coverage at that point. The new survey finds that 32.3 million nonelderly people remain without coverage. While the results found that 49% qualified for Medicaid or subsidized Marketplace coverage, nearly 10% cannot gain access due to state-level decisions not to expand Medicaid. Another 15% of the uninsured, or 4.9 million, are undocumented immigrants who are ineligible for coverage under the ACA.

Of the 20 states that have not expanded Medicaid, those with the largest numbers in the coverage gap are: Texas, with 766,000; Florida, with 567,000; Georgia, with 305,000; North Carolina, with 244,000; and Louisiana, with 192,000.

According to a report accompanying the KFF survey, in states that did not expand Medicaid, nearly 1 in 5 (19%) of those who remain uninsured fall into the coverage gap, while about two-third as many are eligible for Medicaid under rules that existed before the ACA took effect. In fact, states like Alabama and Mississippi have seen a surge in Medicaid enrollment despite the lack of expansion due to increased awareness about eligibility criteria.

Nationwide, an estimated 8.5 million are eligible for Medicaid but have not enrolled, and another 7.1 million are eligible for tax credits on the Marketplace but have not signed up for coverage. Thousands remain eligible for Medicaid in non-expansion states, which suggests these households have always been eligible but for some reason have not obtained benefits, including 493,000 residents in Texas, 306,000 in Florida, and 201,000 in Georgia. In states that have expanded eligibility, KFF estimates that 1.4 million Californians have not claimed Medicaid benefits, as well as 548,000 in New York, 477,000 in Pennsylvania, and 404,000 in Ohio.  

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