Medicaid is a joint federal and state program that currently provides insurance coverage to approximately 67 million Americans [1]. Since the establishment of Medicaid in 1965, the federal government has defined minimum eligibility criteria. For most of Medicaid’s history, these criteria have included income and asset requirements, as well as categorical eligibility, which is defined as membership in medically vulnerable groups such as pregnant women, children, and people with disabilities [2]. Nondisabled adults aged below 65 who were not pregnant or did not have dependent children were traditionally not eligible for Medicaid, unless the state had received a waiver to expand coverage [3].
A key feature of the 2010 Affordable Care Act (ACA) was expansion of Medicaid eligibility to most persons under 138% of the federal poverty guidelines (FPG), regardless of categorical eligibility. The ACA also created insurance exchanges where individuals between 100% and 400% of the FPG could purchase private health insurance at subsidized rates [4]. Together, these provisions were intended to ensure low-income individuals without access to affordable employer-based health insurance could obtain coverage.
Though the ACA expansion of Medicaid eligibility was intended to be mandatory for all states, a 2012 Supreme Court ruling effectively made this provision optional, resulting in a “Medicaid gap” in states that chose not to expand[5]. In non-expansion states, individuals in the Medicaid gap have incomes below 100% of the FPG and are therefore not eligible for subsidized health coverage in ACA marketplaces. Additionally, they either do not fall into one of the traditional Medicaid eligibility categories or do not qualify because income requirements in some categories are set well below the FPG [6]. Nearly 80% of individuals who fall in the Medicaid gap are estimated to be childless adults, and 60% are estimated to work full- or part-time [5].
In North Carolina, Medicaid covers nearly 2 million North Carolinians, approximately 18% of the state’s population [6]. As of 2019, North Carolina remains among the 14 states that have not expanded Medicaid coverage [7]. With few exceptions, North Carolina Medicaid does not cover non-disabled, childless adults at any income level. For parents of dependent children to qualify for Medicaid in North Carolina, their income must be below 43% of the FPG [8]. This results in
an estimated 208,000 low-income adults in North Carolina without access to subsidized health insurance coverage [5].
Individuals in the Medicaid coverage gap have limited ability to obtain health insurance coverage, meaning they may face worse health care access and health outcomes. A better understanding of the relative health status and access to care for those in the Medicaid gap will help to shape policy solutions for addressing the health needs of this population.