Thread by @larry_levitt

Possibly the biggest gap in the ACA is that there are 2.2 million poor, uninsured people who have no affordable health care options in the dozen states that have not expanded Medicaid.

kff.org/medicaid/issue…

There are two leading options being discussed to cover poor people in states that have not expanded Medicaid.

1. Make people below poverty eligible for subsidized coverage in the ACA marketplace.

2. Create a Medicaid backup plan administered by the federal government.

Using the ACA marketplace is likely the quickest and easiest approach to fill the Medicaid coverage gap, since it already exists.

It's also likely the most expensive approach, since private insurers pay higher prices for health care than Medicaid.

Creating a federal backup plan in states that have not expanded Medicaid could be a less expensive option, but it requires an administrative infrastructure that doesn't now exist.

The federal government currently just oversees state Medicaid plans.

The biggest challenge in filling the Medicaid coverage gap is the potential unintended consequences in states that have already expanded and are paying 10% of the cost.

Would some current expansion states drop coverage to save money if a federal backup exists?

Offering fiscal carrots to states that have already expanded Medicaid could encourage them to maintain expanded coverage even if a federal backup exists. It also costs more money.

If the federal government steps in to cover people in states that have not expanded Medicaid, there may be a sense that those states have been let off the hook.

A penalty of some sort could help to offset the cost of a federal backup, but it might run into legal problems.