Filling the Gap in Health Coverage Among the Poor

Each Monday we feature one article from Capital Commentary, a weekly current affairs publication by the Center for Public Justice. To read more, visit

One of the major moral drivers of the push for health care reform in the U.S. was the unconscionable number of uninsured Americans—close to 50 million, many from low-income working families—who lacked access to quality health care. Although the details of health policy are enormously complex, the justice of providing basic, necessary health care to poor Americans is fairly simple. But is the president’s landmark health care reform legislation accomplishing this goal?

Medicaid is the primary program that provides health insurance to needy Americans. A federal/state government partnership, Medicaid and its corollary program, the Children’s Health Insurance Program (CHIP), primarily serve poor children, pregnant women, the disabled and some parents. Poor adults without children have generally not been covered by Medicaid in most states. Income thresholds for eligibility vary by state and among beneficiaries, but range from 50 to 133 percent of the federal poverty line. The federal government bears 50-75 percent of the cost, depending on the state, and the state provides matching funds.

For those adults whose annual income falls between 100 and 400 percent of the federal poverty line, under Affordable Care Act (ACA) the federal government will provide subsidies on a sliding scale for the purchase of health insurance in regulated insurance marketplaces. The ACA also required states expand Medicaid to include adults and families at or below 138 percent of the federal poverty line, but this mandate was declared unconstitutional by the Supreme Court. As a result, states are free to choose whether or not to expand Medicaid eligibility—and accept the accompanying federal funds. Most of the cost of the expansion, starting at 100 percent in years 2014 and declining to 90 percent by 2019, will be borne by the federal government.

Some governors have already agreed to the expansion. In some of these states, such as New Jersey, Medicaid eligibility was already very broad, so under the ACA the federal government is merely picking up more of the tab for people already covered. Other governors have patently refused—some for ideological reasons and some because they are concerned about the federal government’s ability to bear its promised share of the cost. Medicaid spending, along with Medicare and other health care spending, is expected to grow over the next 10 years, so that by 2022, over 55 percent of federal spending will be eaten up by Medicaid, Medicare and Social Security.

Budget constraints and the number of citizens below the poverty line also vary dramatically from state to state, so that a state like Mississippi has a disproportionately high percentage (22.6 percent) of residents below the poverty line, compared to New Hampshire with only 8.8 percent of residents below the federal poverty line and a higher tax base to boot. Some states cannot afford their current Medicaid obligations, so even the prospect of paying for 10 percent of the cost of newly-eligible beneficiaries is daunting.

So where does all this leave poor Americans? And how do we balance extending health care to those who need it today against our obligations of financial stewardship, particularly for coming generations? Certainly, because of the Supreme Court’s decision to let the states choose whether to take advantage of the Medicaid expansion, millions fewer uninsured will be able to obtain health coverage. But because of some systemic issues within the Medicaid program, the impact on their access to health care is harder to assess.

As is often the case in politics, the gap in coverage among low-income adults will not be easily remedied through any act of Congress or the White House. But that does not mean that Christians need to sit on the sidelines and wring their hands, ranting either against the Court or the governors who refuse to expand Medicaid.

Thankfully, the federal government is not the only institution capable of delivering health care to the poor. Around the country, free health clinics are providing medical and dental care to thousands of uninsured Americans. You can find out if such a clinic exists in your community by searching the website of the National Association of Free & Charitable Clinics, a membership organization who advocates for these clinics and distributes guidelines on best practices. Some preliminary studies indicate that at least 2 million people receive treatment at these clinics annually, resulting in significantly fewer unnecessary visits to the emergency room. Some medical schools now have associated free clinics, providing their students an opportunity to learn and serve an underserved population.

Free and charitable clinics are not a silver bullet for improving access to health care among low-income Americans, but neither is the Medicaid program. There is room for modest federal action—some of which may not even require Congress—to encourage the proliferation of these clinics around the country, perhaps offering some loan forgiveness for medical professionals in return for volunteer service at these clinics. The government could also fund clinics to experiment with novel ways of delivering health care affordably to a poverty-stricken community. Or, instead of relying on Medicaid, the federal government could offer subsidies to Americans below the poverty line to purchase private insurance.

Yes, Christians must persistently urge Congress to meaningfully reform health entitlement programs such as Medicaid so that they perform more efficiently and are more sustainable for future generations. And you may want to urge your governor to accept the federal Medicaid expansion. But Christians—even those without any professional medical training—can also improve the lives of the uninsured by supporting or volunteering at free or charitable clinics in their local communities. And if there isn’t one? The NAFCC provides guidelines on how to start one.

—Michelle Crotwell Kirtley is the Editor of Capital Commentary, a Trustee of the Center for Public Justice and a former health and science policy advisor on Capitol Hill.