The Coverage Gap: A Crisis for the Uninsured in Non-Expansion States
The Affordable Care Act (ACA) aimed to expand health care access to millions of Americans, but in several states, a significant gap remains for individuals who earn too much to qualify for Medicaid but too little to afford private insurance through the federal marketplace. Kiana George, a 30-year-old mother of a 9-year-old from Camden, Alabama, is one of those caught in this coverage gap. She works at a child care program but earns just enough to disqualify her from Medicaid. Without insurance, she avoided seeking medical care for her high blood pressure, which eventually landed her in the hospital with mounting debts. “If I don’t have money to get insurance, I don’t have the money to pay you for not having insurance,” George explained, highlighting the financial desperation faced by many in her situation. Her story is not unique; according to a report by KFF, a health policy research organization, approximately 1.4 million people in the 10 non-expansion states are trapped in this same predicament. These individuals are forced to choose between their health and financial stability, often with dire consequences.
The Push for Medicaid Expansion in Alabama and Beyond
Advocates in Alabama and other non-expansion states are urging lawmakers to reconsider their opposition to Medicaid expansion, emphasizing that it would alleviate suffering for working families and support struggling health care providers. However, their efforts come at a time of growing uncertainty about the future of Medicaid at the federal level. Potential cuts and changes to the program have made some state leaders hesitant to act, fearing financial repercussions. Republican House Speaker Nathaniel Ledbetter of Alabama has expressed reluctance, stating that expanding Medicaid now would be “cost prohibitive” and that many are adopting a “wait and see” approach regarding federal actions. Meanwhile, advocates argue that inaction is costing lives and damaging the state’s health care infrastructure. “People are suffering and dying. Hospitals are closing. Alabama is losing billions of dollars that could have been invested in our health care system,” said Debbie Smith of Cover Alabama, a group pushing for expansion.
The Affordable Care Act and the Medicaid Expansion Debate
The ACA originally mandated that states expand Medicaid to cover adults aged 19 to 64 with incomes up to 138% of the federal poverty level—approximately $21,597 for a single person or $29,187 for a family of two. However, a U.S. Supreme Court ruling made this expansion optional, leaving 10 states—Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming—opting out. Without expansion, individuals earning above the Medicaid threshold but below 100% of the poverty level fall into the coverage gap. These individuals are ineligible for both Medicaid and federal subsidies to purchase private insurance through the ACA marketplace. Angelica McCain, a 35-year-old from Hoover, Alabama, who worked in the restaurant industry, described the impossibility of affording private insurance without subsidies. “You can’t expect workers, when you are not paying them a livable wage, to be able to afford privatized health care because it is upward of $500 a month per person,” she said.
The Devastating Consequences of Inaction
The consequences of not expanding Medicaid are far-reaching. In non-expansion states, the uninsured rate is nearly twice as high as in states that have expanded Medicaid—14% compared to 7.6%, according to KFF. Hospitals, particularly in rural areas, are bearing the brunt of uncompensated care, leading to financial strain and even closures. Since 2011, 15 hospitals in Alabama have shut their doors, impacting not just the uninsured but entire communities. “When a hospital is closed, it’s not just closed for the uninsured. It’s closed for all of us,” warned Dr. Don Williamson, president of the Alabama Hospital Association. The closure of these facilities reduces access to critical health care services for everyone, exacerbating public health challenges. Meanwhile, individuals like George and McCain are forced to delay or forego essential care, leading to preventable emergencies and long-term health complications.
Why Medicaid Matters in States Like Alabama
Proponents of Medicaid expansion argue that it is essential for addressing the unique challenges faced by low-income individuals and families in states like Alabama. The state’s Medicaid program currently covers only a limited population, including children, people with disabilities, and pregnant women—a “bare-bones” program, as Smith described it. With no room for cuts, further reductions would only worsen the crisis. Expanding Medicaid would not only provide health care to tens of thousands of Alabamians but also inject billions of federal dollars into the state’s economy, creating jobs and supporting local health care providers. Moreover, it would address the moral imperative to ensure that no one has to choose between their health and their financial stability. As Smith put it, “Meanwhile, people are suffering and dying. We have a responsibility to act.”
The Uncertain Future of Medicaid and the Need for Action
Despite the clear benefits of Medicaid expansion, the political landscape remains uncertain. Many Republican lawmakers in non-expansion states remain skeptical, citing concerns about costs and potential changes at the federal level. Mississippi Gov. Tate Reeves has even called on lawmakers to oppose expansion efforts, pointing to the possibility of changes under a potential Trump administration. However, advocates argue that waiting is no longer an option. The human cost of inaction is too high, and the benefits of expansion far outweigh the risks. As the debate continues, the stories of individuals like Kiana George and Angelica McCain serve as a stark reminder of the urgent need for solutions. For millions caught in the coverage gap, the difference between expansion and inaction is not just about policy—it’s about life and death. The time to act is now.
