Black and Hispanic Lawmakers Push to Keep Medicaid Expansion in Democrats’ Plan

Powerful blocs of Democratic lawmakers are fighting to keep a proposed expansion of health coverage for lower-income Americans in President Biden's social spending and climate agenda, hoping to survive a cull of programs as the party trims the package's price tag.

The congressional Black and Hispanic caucuses, as well as civil-rights groups, have given priority to an expansion of health coverage for people in the dozen states that haven't expanded Medicaid eligibility, looking to help people who don't qualify under their states' current rules but can't afford other coverage.

The proposal appears poised to make it into the roughly $1.75 trillion package currently under negotiation, according to lawmakers and aides, despite some objections from Sen. Joe Manchin (D., W.Va.), a centrist. But lawmakers' original vision of a new federal Medicaid program designed to permanently fill gaps in coverage, with an estimated price tag of more than $300 billion over 10 years, is expected to be significantly pared back.

Democratic leaders are likely to make people who would have qualified under an expanded state program eligible instead for expanded Affordable Care Act subsidies for three or four years, according to aides. The change would mean giving those people financial help to buy private insurance, rather than providing them with government-run insurance under Medicaid.

"We are unified in our commitment to make sure that Medicaid expansion stays in this bill," Sen. Raphael Warnock, flanked by fellow Georgia Democratic Sen. Jon Ossoff, told reporters Tuesday.

The issue has been embraced by Democrats as a civil-rights measure, as Black and Hispanic Americans comprise more than half of people without health coverage, outpacing their share of the overall U.S. population, according to estimates from the Center on Budget and Policy Priorities, a left-leaning research and analysis group.

"One of the biggest injustices our communities are facing is lack of access to affordable healthcare," said Rep. Robin Kelly (D., Ill.), chairwoman of the Congressional Black Caucus's health braintrust, at a press conference Wednesday.

For many Democrats, expanding health coverage in holdout states is an unfulfilled goal of the ACA, which included a provision expanding Medicaid. The Supreme Court in 2012 ruled that states have the option to expand the program or not, and some chose not to.

In states that didn't expand Medicaid, coverage for adults is limited. In nearly all the non-expansion states, childless adults aren't eligible. The median income limit for parents in these states is 41% of the federal poverty level, or an annual income of $8,905 for a family of three in 2020, according to the Kaiser Family Foundation.

Fixing the so-called Medicaid coverage gap has been an aim of many House Democrats who represent holdout states, including House Majority Whip James Clyburn (D., S.C.). But it has come under pressure as lawmakers have sought to divvy out funding among their other healthcare priorities, which have also been scaled back.

For instance, a separate push to broaden Medicare to include dental, hearing and vision benefits remains up in the air due to opposition from Mr. Manchin and fellow centrist Sen. Kyrsten Sinema (D., Ariz.).

Twelve states, including Texas, Florida and Georgia, haven't expanded Medicaid. In some states such as Missouri, voters approved expansion in ballot initiatives that have been blocked by state lawmakers or governors. Republicans argue the expanded program would be too costly for the state and have objected to Democrats' latest proposal to expand the ACA there.

"Of the new people they're covering, the cost is $150,000 a person over 10 years. It's a lot of spending," said Sen. John Barrasso (R., Wyo.).

Under the proposal, Congress would eliminate the income eligibility floor for qualifying for the ACA's premium tax credits, which help reduce premiums. Lower-income people in non-expansion states would be eligible for the financial help.

Mr. Manchin, whose home state has expanded Medicaid, has raised concerns about whether the proposal would reward states that held out. The ACA covers 90% of a state's cost of expanding Medicaid, with states shouldering the other 10%. Congress passed Covid-19 rescue legislation this year to entice holdout states to expand Medicaid. It temporarily provides a five-percentage-point increase in the state's traditional matching rate for two years if they implement the expansion.

"For states that held out and being rewarded 100% is not fair," Mr. Manchin said, although he noted that Democrats had intended for the ACA to expand Medicaid in all 50 states.

Supporters argue that residents of states whose governors chose to not expand Medicaid shouldn't be punished for where they live.

"They didn't decide not to expand Medicaid. They just wake up every day in the state of Georgia," Mr. Warnock said.

Lawmakers have stressed to Mr. Biden and Democratic leaders that if they want to follow through on their promises to help communities of color, expanding Medicaid healthcare coverage is a major avenue to do so. As far back as May, more than 60 civil rights and other groups wrote to Congress urging lawmakers to fix the Medicaid coverage gap.

"Covering the Medicaid gap is very important, not just to save lives for the American people, but also to address equity and the disparities we see among communities that face health disparities," said Rep. Raul Ruiz (D., Calif.), chairman of the Hispanic Caucus.

Civil-rights groups also emphasize maternal health. While women in states that didn't expand Medicaid qualify for Medicaid if they become pregnant, there is often a wait, and they can miss out on prenatal care. The Congressional Black Caucus's Ms. Kelly has pushed for the social-policy package to include a provision that would expand Medicaid's postpartum coverage to one year, up from 60 days.

The proposal's advantage over setting up a new federal program is that it could be done quickly, as early as January, said Judy Solomon of the Center on Budget and Policy Priorities, a nonprofit that advocates on behalf of low-income people.