A cruel disparity exists in the US. Most states in the nation currently recognize two separate groups of the poor—the “deserving poor” and the “undeserving poor.”[1] The deserving poor include pregnant women, children and their parents or caregivers, and the disabled. The undeserving poor largely consist of childless adults. The deserving poor are provided with health coverage through the Medicaid program. The undeserving poor—no matter how destitute they are—do not qualify for Medicaid benefits. As of 2006, there were about 9 million adults without dependent children living under the poverty line who were uninsured.[2]

What this means is that if a worker without dependent children lost their job last year and their household income essentially dropped to $0, they still would not quality for health care coverage through Medicaid in most states. And if they did have dependent children? Whether they qualify or not depends on the state they live in. States have varying income thresholds for Medicaid eligibility. For instance, in Arkansas as of 2009, low-income parents must earn below 17% of the federal poverty line to qualify for Medicaid. In 2009, the poverty line for a family of four was $22,050. Astonishingly, in Arkansas, parents in a family of four earning $4,000 would make too much to be eligible for health care benefits under Medicaid. On the other hand, in a state like New Jersey, parents in a family of four earning $44,100 would qualify.

These bizarre disparities in the Medicaid program can be explained by the history and evolution of the law. Medicaid is financed jointly by the federal government and the states, but is administered at the state level. Originally, Medicaid was created to be a health coverage supplement for those who received cash welfare assistance, which explains why only certain categories of the poor such as pregnant women, mothers, or the disabled, were eligible. Over time, Congress and the states have expanded the Medicaid program to help cover the growing number of low-income individuals who did not have access to other forms of health insurance. Each state’s Medicaid program has evolved differently depending on the political and economic climate of the individual state.

Although far from perfect, Medicaid serves a vital purpose in our system today. Medicaid stands as the indispensable insurer of health care to the most vulnerable in our population—providing health and long-term care services to nearly 60 million Americans. Medicaid provides benefits to more individuals than any other public or private insurance program in existence, including Medicare. Yet, large segments of the very poor are still excluded from the critical benefits that Medicaid can offer.

For the first time ever, the Affordable Care Act will change this. The new law sets a national floor for income eligibility in the Medicaid program at 133% of poverty ($14,404 for an individual or about $29,326 for a family of four). Large variations in state eligibility will be eliminated, and finally, poor adults without dependent children will be eligible for health benefits through Medicaid. Medicaid will finally be a public health insurance program for (almost) all the poor.[3]

This Medicaid expansion is not insignificant. It will be responsible for nearly half of the newly covered under health reform—an estimated 16 million people by 2019, according to the Congressional Budget Office. The associated costs are not trivial either. The expansions will cost the federal government an estimated $434 billion from 2010 to 2019, financed through program savings and new taxes on insurance companies (but will not raise the federal deficit).

Those wondering whether the investment is worth it need only ask themselves whether the US is a country that ought to deny individuals and families who live at the bottom of the socioeconomic ladder access to health care. An annual income of $14,404 is not an awful lot to live on. In passing health reform, we as a society have decided that our neighbors who make less than this ought to have some help in case they get sick—whether they are parents, pregnant, disabled, or not. We’ve already decided that we ought to provide emergency stabilizing care to anyone who walks into an emergency department. Now we need to provide a little help on the front end for the most vulnerable. The expansion of Medicaid by health reform will finally make this a reality.

[2] These individuals had annual incomes below $9,800 if they were single,$13,200 in a two-person household. Source: Low-Income Adults Under Age 65—Many are Poor, Sick, and Uninsured, Kaiser Commission on Medicaid and the Uninsured, June 2009

[3] Only American citizens and lawfully residing immigrants who have lived in the US for more than five years can qualify for Medicaid.