In March 2021, Congress passed unprecedented levels of federal funding incentives in the American Rescue Plan (ARPA) to encourage states to adopt Medicaid expansion. State and local health advocates have utilized these new funding incentives in addition to the extensive list of benefits to be gained from expanding Medicaid to push for solutions to close the coverage gap for  2.2 million uninsured adults. And yet, we continue to hear racist and partisan arguments at the state level with no basis in fact and no supporting evidence. Time and time again, we come to the same conclusion regarding Medicaid expansion: it allows low-income adults to have a realistic avenue to needed health care services and allows the state to reap the benefits in its state budget and various sectors; while the decision not to expand presents serious access and equity concerns. As highlighted by members of the Congressional Black Caucus, the Congressional Hispanic Caucus, and the Congressional Asian Pacific American Caucus, closing the coverage gap is one of the single most important steps we can take to reduce health inequities across the United States, as almost 60 percent of people affected by the coverage gap are people of color.  

Frustration over the lack of action in the remaining non-expansion states has led U.S. Rep. Lloyd Doggett of Texas to file legislation, the COVER Now Act, which would redefine the process of Medicaid expansion by allowing regions within a non-expansion state to opt into expansion, rather than depend on its state legislature to make that decision. We commend Rep. Doggett for his commitment to closing the coverage gap in his proposal, but we believe that this proposal could present challenges to the implementation of Medicaid expansion and leave consumers confused about who is covered. We believe that this is a good start to conversations on how we can effectively find other ways to close the coverage gap.  

What’s in Rep. Doggett’s bill? 

Rep. Doggett’s bill would give counties and other political subdivisions in non-expansion states the option to expand Medicaid as a demonstration project. Interested regions would be required to undergo the same administrative processes, including a public comment period at the state level, and would receive the same federal funding (and ARPA incentives) as if the entire state had expanded. Furthermore, if the state does choose to adopt Medicaid expansion at a later date, eligible beneficiaries would be automatically enrolled into the state Medicaid expansion plan.  

More Questions than Answers 

Rep. Doggett’s bill is a testament to how determined advocates and stakeholders are to close the coverage gap. Political tensions that obstruct health care access lead many to believe that an alternative option bypassing unreasonable state legislatures is the only option. We applaud Rep. Doggett for shining light on the deep inequities that people in non-expansion states face. However, we must strongly consider the impacts of the way in which we close the coverage gap. While well-intended, this bill could lead to more questions than answers, for example: can patients with Medicaid coverage in an expansion county seek care in a non-expansion county? How does an expansion region ensure network adequacy if surrounding regions have chosen not to expand? Would a provider need to set varying reimbursement rates for people of different counties? Moreover, the demonstration projects through this option would help some, but not all, people living in non-expansion states and would result in beneficiary confusion, unintentionally serving as an argument for Medicaid expansion critics that closing the coverage gap causes more harm than good. 

There is growing support to help all eligible people in non-expansion states, let’s take up that drumbeat and not limit ourselves to a partial solution. We encourage legislators to use the Doggett proposal as an opportunity to think through key questions and identify a pathway that serves all people equitably. We offer a set of principles to guide that process here. One thing is clear: now is the moment to be bold and finish the work of the ACA – we must close the gap and ensure that people have access to health coverage.