Health care reform: Expanding Medicaid for lowest-income adults

As the national health care reform debate continues to heat up, most of the controversy has centered on such hot-button issues as the public  option, individual and employer mandates, and paying for expanded coverage. One issue that is of considerable significance to states and low-income advocates in particular, but that has received far less attention, concerns the Medicaid program, the existing state-federal health care program for certain low-income individuals and families.

Poverty, poor health, and inadequate access to health insurance coverage are strongly correlated.  Adults living in poverty are one of the largest segments of Oklahoma’s uninsured population. According to the Kaiser Family  Foundation, 55 percent of poor adults were without health insurance in Oklahoma in 2006-2007, the fifth highest rate in the nation. There were 194,410 uninsured adults below the poverty level in 2006-07 ($22,050 for a family of four in 2009). This group represents almost two-fifths (38 percent) of all uninsured adults and just under one-third (30 percent) of the entire uninsured population in Oklahoma.

Few adults in poverty are covered by private insurance, either because they are not working or are not offered or cannot afford employer-based coverage. Some believe that if you’re poor, you automatically qualify for public health insurance.  But that’s not the case. Until recently, most adult Oklahomans living in poverty were ineligible for any public health insurance programs unless they were pregnant, elderly or had a disability. Medicaid in Oklahoma covers only parents of dependent children up to 50 percent of the federal poverty level ($763 per month in 2008 for a family of three). Parents of children with income above 50 percent of poverty, as well as childless adults under age 65, were ineligible for coverage.

With implementation of the Insure Oklahoma program, adults below the poverty level became eligible for subsidized coverage either through their employer or the state-administered Individual Plan. However, participation in Insure Oklahoma requires the enrollee to pay a portion of premiums and other cost-sharing expenses up to a maximum of 5 percent of family income. These cost-sharing obligations appear to create a huge barrier to participation in Insure Oklahoma among those living in poverty. While the program has now grown to cover over 20,000 individuals, just one in four participants has income below the poverty level.

Proposals emerging out of committees in both the U.S.  House and Senate would require states to expand Medicaid eligibility to cover all adults up to 100 percent or 133 percent of  the federal poverty level.  In the Senate Finance committee version, states would have three years to phase in eligibility to 100 percent FPL; the federal government would provide an increase in federal funding for the new eligibility categories for five years and then phase down to the regular state match.

The proposal poses some genuine challenges that will need to be addressed by Congress and the states, including the increased obligations this could place on state budgets, finding effective ways to ensure that those who are Medicaid-eligible actually enroll in the program, and ensuring adequate access to services for Medicaid recipients. Still, expanding Medicaid seems like the right approach. It is an established program that provides cost-effective coverage at low or no expense for participants and offers a comprehensive benefits package, which is especially important for the poor, who frequently have chronic and complicated health problems.

There is little doubt that having access to consistent, affordable care will help keep low-income adults healthier, creating a foundation that will help lift families out of poverty and towards economic security. If health care reform can succeed in covering most of the sizable uninsured below-poverty population through Medicaid, that will be one its worthiest accomplishments.


Former Executive Director David Blatt joined OK Policy in 2008 and served as its Executive Director from 2010 to 2019. He previously served as Director of Public Policy for Community Action Project of Tulsa County and as a budget analyst for the Oklahoma State Senate. He has a Ph.D. in political science from Cornell University and a B.A. from the University of Alberta. David has been selected as Political Scientist of the Year by the Oklahoma Political Science Association, Local Social Justice Champion by the Dan Allen Center for Social Justice, and Public Citizen of the Year by the National Association of Social Workers.

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