ACA Data Note: Who's Left Behind without the ACA Medicaid Expansion?

July 3, 2012: From the desk of SHADAC Director Lynn Blewett

The Supreme Court (SCOTUS) decision, at first blush, seems straight forward and quite clear.  The individual mandate is upheld as a tax and the Medicaid expansion is now optional to states.  But the Medicaid issues that have arisen in the few first days since the SCOTUS ruling are quite complex.  One significant issue: If states are no longer required to expand their Medicaid programs to 138% of FPL, what does that mean for the low-income populations in states that don’t expand? 

If States Don't Expand Medicaid...

If a state does not pursue the Health Insurance Exchange, the federal government will develop its own Exchange within the state.  However, for states that choose not to expand Medicaid, the federal government will not step in.  Individuals between 100 and 138 percent FPL could buy subsidized coverage through the Exchange, but they will face much higher costs than they would have faced with Medicaid.  What's more, the uninsured below 100 percent FPL--i.e., the poorest of the poor--will have no viable coverage options whatsoever in states that choose not to expand Medicaid, since this group is not even eligible for Exchange coverage. 

Who Would Be Left Behind?

The table below provides information on the numbers of individuals in each state with incomes below 138 percent FPL and their rates of uninsurance based on 2010 American Community Survey (ACS) data.  This is a first look at who could be left behind if a state opts out of the ACA Medicaid expansions. 

A few key points:  We estimate 22 million uninsured adults in the United States with incomes below 138 percent FPL.  Texas, Florida, and California, have the largest numbers of uninsured below 138 percent FPL, with 2.6 million, 1.8 million, and 3.2 million respectively.  States with the lowest number of uninsured below 138 percent of poverty include Vermont, North Dakota, and Wyoming, with 14,900; 25,509; and 29,080, respectively.

For a related Issue Brief with state estimates, see "State Estimates of the Low-income Uninsured not Eligible for the ACA Medicaid Expansion."

View/download table as PDF.