The numbers are good. Despite its rocky roll-out, the ACA has lifted an estimated 5.4 million Americans out of uninsured limbo since September 2013. That’s a drop of 2.7% nationwide—pretty good. But in states that opted into the sweeping Medicaid expansion (meaning everyone making up to 138% the federal poverty level—roughly $27,000 a year for a family of three—can enroll in Medicaid) the numbers are even better. On average, these opted-in states are cutting their numbers of uninsured nonelderly adults by 34%—we’re talking big numbers.
This is obviously great news for folks living in participating states. But what about people living in the opt-out states? What's happening to them? And how are foundations in the healthcare space trying to help the people left out?
To understand this situation, you have to understand a paradox. Though the ACA has made the healthcare situation for low income adults better in states participating in the Medicaid expansion, it may actually be making things worse in non-participating states. How? It’s called the Coverage Gap, comprising those adults making too much to qualify for Medicaid, but not enough to qualify for ACA Marketplace premium tax credits. Couple that with the squeeze hospitals are already feeling to cut costs—due to the drop-off in federal reimbursements for care—and you have, in many ways, a situation exacerbated, not ameliorated, by the Affordable Care Act.
Of course, this is only in the non-participating states. All along, there has been pressure on these states—not just the Texas, Florida, and Mississippi you’d expect, but the Pennsylvania and Indiana too—to take the leap. So what are foundations doing about the Coverage Gap?
Well, for starters they are trying to better understand this problem. For example, the Kaiser Family Foundation has produced great research on what's happening the opt-out states—like this excellent overview. Most recently, Kaiser put out this issue brief looking at the negative consequences of states' decisions not to expand Medicaid—research that's super helpful as pressure grows on governors and legislatures in opt-out states to, literally, get with the program and stop saying no to free Medicaid money.
RWJF, of course, is also on this issue in various ways. Among other initiatives, it's funding a big study on maximizing Medicaid enrollment with the Columbia Mailman School of Public Health that, along with RWJF's other work on the Medicaid expansion, will shed light overall on how this part of ACA can succeed. The Commonwealth Fund is funding work along similar lines.
Beyond such clear-cut initiatives, there's a lot of money moving out to state-based policy and advocacy groups that are pushing for Medicaid expansion in the opt-out states. For example, the Center for Public Policy Priorities in Texas recently launched a campaign called "Texas Left Me Out" that dramatizes the Coverage Gap and the destructive consequences of Texas not participating in Medicaid expansion. The Center has long received support from a number of national foundations, including Annie E. Case, Ford, Heron—although it's not clear if any specific funder is backing the "Texas Left Me Out" campaign.
A number of other red state policy groups are also pressing the case for Medicaid exansion, often working in concert through the State Fiscal Analysis Initiative (which CPPP is Texas is part of). SFAI groups working the Medicaid issue include the Louisiana Budget Project, which has gotten funding over the years from Annie E. Casey, the W.K. Kellogg Foundation, OSF, and other foundations. In Ohio, where a Republican governor did change course and accept Medicaid expansion, another SFAI group, Policy Matters, has fought to get the state government to follow through on this decision. Policy Matters, too, is supported by a number of national and regional foundations.
The work of SFAI groups on Medicaid expansion is backstopped in a variety of ways by the Center of Budget Policy Priorities, the national think tank in Washington which serves as SFAI's mother ship and which pumps out a steady stream of analysis on why Medicaid expansion is a good deal for the states. CBPP gets funding from numerous foundations.
Meanwhile, of course, national healthcare groups—most notably Families USA—have been fighting hard for Medicaid expansion all along, and are doing everything they can to get states to opt-in. For example, Families USA recently crunched numbers to show how working adults would benefit from Medicaid expansion in Missouri. Families USA has been supported in recent years by foundations like Ford, the California Endowment, and the George Gund Foundation.
Medicaid expansion is a highly politicized issue, and it's no wonder that you don't see a lot of a big grants that go explicitly to push for expansion in the opt-out states. But make no mistake: plenty of foundation-backed groups are working this front every day.