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Medicaid enrollment has increased since President Joe Biden took office. Yuri Gripas/Abaca/Bloomberg via Getty Images
  • The Biden administration is introducing programs to help people in the so-called “coverage gap” in states that haven’t adopted Medicaid expansion plans.
  • Some proposals could target new mothers, older adults living at home, and prison inmates who need treatment for addiction.
  • Experts say the pressure is building on the holdout states to approve Medicaid expansion.

An estimated 2 million people in the United States fall into the so-called “coverage gap.”

They live in the dozen of states that turned down Medicaid expansion under the Affordable Care Act, more commonly known as Obamacare.

So even though these folks fall below the poverty line, they still don’t qualify for Medicaid in those states. The Center on Budget and Policy Priorities says 60 percent of them are People of Color.

President Joe Biden has sweetened the pot in an effort to get the dozen holdout states to expand Medicaid. The president’s American Rescue Plan contains more matching of federal funds as an incentive.

The Kaiser Family Foundation estimates that’s nearly $10 billion in federal funds over 2 years to those states. So far, however, there are no takers.

Experts say this is the president’s most challenging hurdle, especially in the current political climate. Meanwhile, Biden is focusing on things he can get done.

“Everything Biden is doing now is very incremental,” said Eric Seiber, PhD, a professor in the College of Public Health and director of the Center for Health Outcomes and Policy Evaluation Studies at The Ohio State University.

“Let’s try to do a little better for a few more people. They’re doing innovations around the edges. And they’re doing it with one and a half hands tied behind their backs,” Seiber told Healthline.

The economic downturn from the COVID-19 pandemic and a loss of jobs, along with some easing of the requirements to qualify for Medicaid, has resulted in record enrollments.

Over the past year, enrollments in the program has spiked from about 72 million to 80 million.

The Biden administration is rolling back rules implemented during the presidency of Donald Trump that gave states permission to require low-income residents to either work, go to school, or start job training before they could enroll in the program.

Another provision in the Biden COVID-19 relief plan allows states to provide Medicaid coverage for new mothers up to a year after they give birth. That’s a change from the 60 days previously allowed under federal law.

There’s also additional funding in the American Rescue Plan to increase Medicaid home and community-based healthcare for older adults and people with disabilities. The goal is to keep more people in their own homes and out of nursing facilities.

States are reportedly lobbying the White House to move on other provisions, including Medicaid for undocumented immigrants in California. There’s also a renewed push to use Medicaid funds to treat prison inmates for addiction while they’re incarcerated, instead of waiting until they get out.

“The American Rescue Plan gave him more money to work with, but they still have to operate in a very strictly defined regulatory frame,” Seiber said.

“He’s definitely picking the proposals where he has a decent chance obviously,” added Chris Pope, PhD, a senior fellow at the Manhattan Institute in New York.

“They’re sort of taking the low-hanging fruit and there’s a lot of money to play with,” Pope told Healthline.

“I do believe that eventually every state will say yes because the money is too good,” Seiber said. “The hospitals will pressure them because everybody would have health insurance at that point. There’s no uncompensated care.”

The ballot box is also proving to be a motivator. Voters in Oklahoma approved Medicaid expansion in June 2020. The plan began this month.

Voters in Missouri also approved Medicaid expansion in August 2020. However, state lawmakers wouldn’t fund it. The Missouri Supreme Court will hear the dispute in this case next week.

Pope said the Biden administration might be headed toward a new federal program.

“I wouldn’t be surprised if they come up with some federal public option that only the expansion population is eligible for,” he said.

“It has the added political bonus of being able to tell the left of the Democratic party, ‘See what we did… we took a first step on the path to public option,’” he explained. “But that could run into some political hurdles. There’s a very, very small Senate majority.”

One of the ideas recently floated by Georgia’s two new senators, Raphael Warnock and John Ossoff, is to create a “federal Medicaid look-alike program” to be run by the Centers for Medicare and Medicaid Services.