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The Medicaid Expansion promotes social justice through equity

August 21, 2013
by Ron Manderscheid
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We can improve the health status and care access of uninsured persons who suffer from poverty.

The Affordable Care Act (ACA) created a state Medicaid Expansion Initiative to provide health insurance coverage for the remaining population of uninsured adults who suffer from poverty. The program was designed as a primary tool to promote social justice. The population of poor persons has worse health status and worse health care access than do other Americans. The Medicaid Expansion seeks to redress these disparities by promoting equity through expanded health insurance coverage.

The US Supreme Court determined in 2012 that the ACA Medicaid Expansion is at state option rather than mandatory.  Nationally, the initiative has the potential to provide health insurance coverage to about 18 million poor Americans, 40 % of whom have one or more behavioral health conditions. Hence, the Medicaid Expansion is of critical importance for behavioral healthcare, and it is essential that we understand its structure and operation.


The Initiative.  In a quest to achieve universal coverage, the Medicaid Expansion was designed originally to be an ACA tool to extend health insurance coverage to all uninsured adults who are poor. As a result of the Supreme Court decision, only 26 states and DC are undertaking the Medicaid Expansion in 2014; 4 additional states are undertaking an alternate model (see below); 13 states have determined that they will not undertake the Initiative; and 7 states have not yet made a decision. You can learn more about your own state at:

Fully 100 % of the cost of the Medicaid Expansion will be paid by the federal government for 2014, 2015, and 2016. Subsequently, this amount will decrease gradually to 90 % by 2020, where it will remain permanently. As such, the Medicaid Expansion is an extremely important tool for providing financial resources to states to address the lack of health insurance among persons who are poor. Currently, these persons use emergency rooms as a primary source of care at great cost to federal, state, and county governments.

Alternate State Plans. The four states with alternateMedicaid Expansion plans are Arkansas, Indiana, Iowa, and Tennessee. Each of these states must seek an 1115 waiver from HHS to undertake its alternate plan. Generally, a common thread among these plans is the purchase of health insurance through private sector plans offered through the state Health Insurance Marketplace. Likely, the most interesting and creative of these alternate plans is that developed by Iowa. The Iowa plan combines traditional Medicaid Expansion for part of the eligible population (up to 100 % of the Federal Poverty Level (FPL)) with private insurance for the remainder of the population (101–133 % FPL). The Iowa Plan also requires participation in a wellness initiative to address common health problems, such as smoking and obesity, in order to maintain state financial support beyond the first year of coverage. See my analysis of the Iowa plan at:



Ron Manderscheid

Exec. Dir., NACBHDD and NARMH

Ron Manderscheid


Ron Manderscheid, Ph.D., serves as the Executive Director of the National Association of County...

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