Medicaid is the primary government-funded health insurance for low-income Americans available in every state. An expansion of Medicaid  under the Affordable Care Act (ACA) allows more working Americans on low incomes to be eligible for coverage. Holdout states that have not increased Medicaid eligibility may be less prepared to diagnose, manage and treat patients during the Covid-19 crisis, according to recent studies by the government and nonprofit health advocacy organizations.

Before California, 34 other states and the District of Columbia expanded Medicaid under Obamacare, Oakland resident Jamal Ali, like many other low-wage workers in the U.S., put off medical care unless he had an emergency.

Ali, 34, was not offered health insurance in his sales job and could not afford coverage on his own. A lung infection that caused his asthma to flare up prompted Ali to seek urgent care after he had trouble breathing and was at risk of pneumonia.

Ali got the expert medical care he needed plus antibiotics. But it came at a high cost without insurance: $250 in out of pocket costs. Now with Medicaid expansion under the Affordable Care Act – formerly known as Obamacare – Ali says he does not worry about how he will afford treatment if he gets really sick again. “It’s all covered,” said Ali, who proudly showed his Medi-Cal benefits card, which he keeps handy in his wallet.

Ali is among more than 12 million Americans who have received coverage under Medicaid expansion since 2014, and those numbers continue to grow, according to the Center on Budget and Policy Priorities.

The Affordable Care Act , or ACA, was signed into law by former President Obama in 2010, after much debate and controversy in Congress. But it quickly gained popularity with uninsured and under-insured Americans as well as the business community. The new law signaled the biggest Medicaid eligibility expansion since its inception more than 50 years ago. The ACA required states to expand Medicaid to include more working, low-income Americans, but a subsequent U.S. Supreme Court ruling has left the decision to the states.  Not all have followed but pressure by voters is changing that.

Nebraska recently expanded Medicaid, after voters approved a ballot initiative. Maine, Utah and Idaho also approved expansion by vote.


The Center on Budget and Policy Priorities reports that the ACA Medicaid expansion has many benefits. It has helped to close the gap in both quality and access to health care for people of color like Ali, who is African American.Most important during the pandemic, California and other Medicaid expansion states are better poised to respond to the Covid-19 crisis with testing, diagnosis and treatment. Many of the Americans covered by Medicaid under ACA are front-line workers, known as “essential” employees, including hospital workers, grocery stores clerks and cashiers, and home-health aides.

Experts estimate that expanding Medicaid to the holdout states would cover an additional four million Americans, which include 650,000 frontline workers.

Because of his asthma condition, for example, Ali would be at a greater risk of complications if he were to contract Covid-19. But this time around, if he gets seriously ill, Ali said he would not hesitate to seek treatment like he did previously, when he did not have a regular physician and delayed care until it was an emergency.

With many companies shutting down since the pandemic, millions of additional workers have lost employment in 2020, according to the Kaiser Family Foundation. The foundation’s research found that if the remaining states expanded Medicaid eligibility under ACA, their economies would rebound faster as businesses begin to re-open, because of earlier diagnoses, better health outcomes and less financial hardship on individuals and families.

The Center on Budget and Policy Priorities has found that “the lifesaving effects” of Medicaid expansion include people getting regular checkups, improved access to prescription drugs, and more early stage screenings for cancer.


In 2020, the federal government pays 90 percent of the costs, which decreases the financial burden of charity care for uninsured hospital patients, which is passed along through higher health-care costs as well as steeper premiums for all consumers with coverage. Patients not only benefit from better outcomes but health-care providers are assured that they can depend on payment.

In addition, Congress adopted the Families First Coronavirus Response Act, which increases Medicaid costs the federal government will cover during the pandemic, easing the burden on holdout states. It also requires certain employers to provide paid sick leave, through December 2020.

California and other states are reporting a net savings in health-care costs after increasing Medicaid eligibility to include more low-income workers. So-called Medi-Cal brought in up to $3.5 billion in federal dollars in 2014, which grew to $4.5 billion in 2019, according to the UCLA Center for Health Policy Research. In California, a study by the UCLA Center for Health Policy Research concluded that: “Medi-Cal expansion [makes] funding more stable for providers” who care for the uninsured, which improves access to care for low-income communities.

Resistance Resources: The following are nonprofit organizations and government agencies that provide information on Medicaid access and eligibility under ACA and on health coverage during the Covid 19 pandemic.

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