What are the lives of Black, Latinx, and other people with low incomes in the Medicaid coverage gap worth to members of Congress? The answer to that question hangs in the balance amid heated negotiations over the topline cost of the Build Back Better Act, Congress’ budget reconciliation bill.
Jim Crow’s legacy is apparent in a dozen recalcitrant states’ discriminatory refusals to expand Medicaid under the Affordable Care Act (ACA). For nearly a decade, they have left millions of uninsured people with low incomes—disproportionately Black and Latinx people in the South—in the resulting Medicaid coverage gap. The odds are stacked heavily against people in the coverage gap as they weather the deadly COVID-19 pandemic, soaring maternal mortality, and countless other public health challenges, all of which fall hardest on Black, Indigenous, and other people of color. State refusals to expand Medicaid are killing tens of thousands of people—many essential workers, parents, and people with disabilities—each year.
In provisions passed by the House Committee on Energy and Commerce, the Build Back Better Act aims to remedy this injustice by launching a new federal Medicaid program that closely mirrors Medicaid expansion coverage starting in 2025. In the meantime, it would provide temporary ACA Marketplace coverage. Yet depending on the legislation’s new topline budget, the scope, duration, and very inclusion of a federal intervention could soon change. If Congress addresses the Medicaid coverage gap, it must fully invest in a comprehensive solution that guarantees access to the same standard of health coverage and consumer protections that current Medicaid expansion enrollees receive. We cannot accept a substandard fix that undervalues the lives of Black, Latinx, and other people with low incomes.
Medicaid has played a critical role in the struggle for equitable health care access for underserved communities with low incomes since its creation in 1965. For nearly a decade, the ACA’s Medicaid expansion has furthered that work by improving health coverage, access, and outcomes for nearly 14 million people, saving tens of thousands of lives, and narrowing racial health inequities.
Medicaid’s lifesaving magic is in its details: comprehensive health benefits, consumer protections, and other features specifically designed to meet the complex, persistent, and significant health needs of people with low incomes. It provides many specially tailored health benefits and protections that people with disabilities, chronic health conditions, and other people with low incomes need to survive, yet are simply not found in private health insurance, including the Marketplace’s current qualified health plans.
For example, Medicaid offers home- and community-based services for people with disabilities and non-emergency medical transportation for people who cannot otherwise afford to get to appointments. It has strict cost-sharing limits and enrollment protections that ensure people can immediately access care during emergency situations, and prevent medical debt and continued cycles of poverty. These and many other signature features enable Medicaid to save and transform the lives of expansion enrollees in thirty-nine states. People in the Medicaid coverage gap have been left behind. They cannot afford to wait any longer.
Nearly seventy years after the Supreme Court found that “segregation is the denial of equal protection of the laws” in Brown v. Board of Education, our country continues to grapple with structural racism. Any federal solution to the Medicaid coverage gap must ensure beneficiaries have a robust right to the same comprehensive health benefits and protections that Medicaid expansion enrollees receive in states that have already expanded. Absent parity, Congress’ intervention could create a separate and unequal standard of health coverage for millions of Black, Latinx, and other people with low incomes, most of whom live in the South. That weaker standard could be especially dangerous for people with disabilities, chronic health conditions, and other complex health needs.
It could also undermine the future of Medicaid writ large. Current Medicaid expansion states might seek to abandon their expansions, leaving current enrollees to fend for themselves with lesser health benefits and protections. Further, if Congress acquiesces to a lower standard of coverage for certain people with low incomes today, it could inadvertently set precedent for a future Congress to lower Medicaid’s standard of coverage for other enrollees nationwide, costing countless lives.
The Build Back Better Act presents what may be a once-in-a-generation opportunity for Congress to end the Medicaid coverage gap once and for all. If lawmakers proceed with closing the coverage gap, they must fully invest in a comprehensive and equitable solution, and they must tread carefully, lest they undermine our country’s public health insurance safety net. Congress has a vital chance to bend the moral arc of U.S. health policy toward racial justice, but in this case, justice is in the details.
For more information about what an equitable federal Medicaid coverage gap solution must entail, visit NHeLP’s framework of essential elements, “Closing the Medicaid Coverage Gap: Preventing a Separate and Unequal Result.”
For additional information on key considerations, see NHeLP’s recent letter to Congressional leadership.