Medicaid coverage gap

Under the public healthcare policy of the United States, some people have incomes too high to qualify in their state of residence for Medicaid, the public health insurance plan for those with limited resources, but too low to qualify for the premium tax credits that would subsidize the purchase of private health insurance.

It expanded Medicaid by raising the income threshold for eligibility to 138 percent of the federal poverty line (FPL) among nonelderly adults.

Nevertheless, opponents of the ACA asserted that the federal government's conditioning of continued funding for Medicaid on adoption of expansion was unconstitutionally coercive.

However, the U.S. Supreme Court ruling in National Federation of Independent Business v. Sebelius (2012) rendered state adoption of Medicaid expansion optional.

[2] As of March 2023[update], an estimated 1.9 million people are in the Medicaid coverage gap, residing in Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming.

[6]: 2  However, some states set stringent income eligibility thresholds well below the federal poverty level (FPL) for caretakers and parents of minors.

[10][11] The ACA was signed into law in March 2010 by President Barack Obama after passing with narrow majorities in the House and Senate on nearly party lines.

[6] The ACA sought to eliminate categorical criteria barring these groups from Medicaid eligibility and standardize requirements across states.

[26][23] The federal government typically covered only 50–83 percent of Medicaid costs prior to ACA,[26] with its share determined by the state's average per capita income.

[26] In National Federation of Independent Business, the plaintiffs challenged the constitutionality of the ACA and contended that the Medicaid expansion provision was coercive.

[6] The incongruous adoption of Medicaid expansion was a result of several factors, including partisanship and pressure from private insurance stakeholders.

[37][39] On October 13, 2016, Maine Equal Justice Partners, a progressive advocacy group, announced that it would begin canvassing for signatures to hold a referendum on Medicaid expansion in the state.

[39] Question 2 passed with 59 percent of the vote,[38] making Maine the first state to approve Medicaid expansion by ballot measure.

[38][44] Sara Gideon, the Speaker of the Maine House of Representatives, responded by stating that "Any attempts to illegally delay or subvert [expansion legislation]" would "be fought with every recourse at our disposal.

[53][54] Shortly after taking office, Mills signed an executive order on January 3, 2019, directing the expansion of Medicaid and opening enrollments for the program.

[57][58] Tom Coburn, the junior U.S. senator from Oklahoma, wrote a letter to Fallin in October 2012 warning against expanding the state's Medicaid program.

[59] On November 19, 2012, Fallin announced that the state would not be moving forward with Medicaid expansion, citing high costs and the resulting need for budget cuts to other government programs.

[65] In December 2018, in the wake of the 2018 midterm elections, Democrats in the Oklahoma House of Representatives announced that they would legislatively push for Medicaid expansion.

[72] As canvassing for the ballot initiative was ongoing, a bipartisan legislative working group intended to address Medicaid expansion and healthcare coverage began convening and regularly meeting.

[72] Stitt unveiled his proposal, dubbed SoonerCare 2.0, in March 2020; the plan involved expansion of the state's Medicaid program including work requirements and tiered monthly premiums and copays.

[82] In 2015, South Dakota Governor Dennis Daugaard proposed extending Medicaid coverage to 55,000 residents and raising health spending for Native Americans.

[79] A coalition of advocacy groups, including Dakotans for Health, began canvassing for signatures in 2021 to place a constitutional amendment to expand Medicaid on the ballot for the 2022 election.

[80] The passage of Constitutional Amendment D set into motion the expansion of Medicaid to 42,500 new adult and nonelderly South Dakotans by July 1, 2023.

[94][95] The Republican-controlled state legislature was staunchly opposed to Medicaid expansion due to its costs and distrust of the federal government.

[94] While Governor Gary Herbert elected to wait for an independent analysis of Medicaid expansion to make a decision, Republican lawmakers sought to pass a bill prohibiting Medicaid expansion without approval from the state legislature;[96][97] the Utah House of Representatives approved the bill by a 46–27 vote on March 11, 2013.