If you live in one of the ten states that has not expanded Medicaid under the Affordable Care Act, you may have heard that help is available to get health insurance. But for roughly 1.4 million people across those states, that help is simply out of reach. They earn too much to qualify for their state's Medicaid program, yet not enough to qualify for the tax credits that make ACA marketplace plans affordable. This situation is commonly called the coverage gap, and understanding it can help you figure out where you actually stand.
Why the Coverage Gap Exists
The ACA was originally designed so that Medicaid would cover people with very low incomes, and marketplace subsidies would pick up from there. The law assumed all states would expand Medicaid eligibility up to 138 percent of the federal poverty level. When the Supreme Court made that expansion optional in 2012, ten states still have not adopted it as of today.
Here is what that means in practice. If your income falls below the poverty line in a non-expansion state, you likely do not qualify for Medicaid under the old, stricter rules. But ACA premium tax credits only apply to people earning at or above 100 percent of the federal poverty level. The result is a gap where people are left with no affordable option.
Who Is Most Affected
The coverage gap does not affect everyone equally. Research shows that the people most likely to be caught in it include:
- Working adults in low-wage jobs that do not offer employer coverage
- People of color, who are disproportionately represented due to historical and structural inequities in income and employment
- People with disabilities who may not meet the narrow eligibility criteria for Medicaid in non-expansion states
- Adults without dependent children, who often face the strictest Medicaid rules
These are not people who are avoiding coverage. In many cases, they have actively looked for options and found none they could afford.
What You Can Do If You Think You Are in the Gap
If you live in a non-expansion state and are unsure whether you qualify for any coverage, here are some steps worth taking:
- Check your income relative to the federal poverty level. Poverty guidelines are updated each year. Your household size matters, so use current figures when calculating.
- Apply through the ACA marketplace anyway. Income estimates can shift during the year, and if your projected annual income lands at or above 100 percent of the poverty level, you may qualify for subsidized coverage.
- Look into your state's existing Medicaid rules. Some non-expansion states still have Medicaid programs for pregnant individuals, parents with dependent children, or people with specific disabilities. You may qualify under a category you are not aware of.
- Ask about other local programs. Community health centers, federally qualified health centers, and some nonprofit clinics offer sliding-scale care regardless of insurance status.
The Bigger Picture
The coverage gap is a policy problem, not a personal failing. It exists because of decisions made at the state level, and it affects people who are doing everything right. If your state has not expanded Medicaid, advocacy organizations and state legislators are the ones with the power to close that gap.
Practical takeaway: If you are uninsured and unsure whether you qualify for help, start by submitting an application on the ACA marketplace at healthcare.gov. Even if you have been told before that you do not qualify, circumstances change. A licensed broker can also review your specific situation at no cost to you and help identify any options you may have missed.