A handful of states have refused to expand a life-saving healthcare program for years, denying millions of Americans health coverage. They're finally out of excuses.

• Politicians in several red states have resisted expanding Medicaid for more than a decade. 
• Research shows expanding Medicaid is the best way to get more people access to healthcare. 
• With new incentives in Biden’s stimulus package, the expansion will pay for itself. 
• Jonathan Schleifer is the Executive Director of The Fairness Project, a non-partisan nonprofit.
• This is an opinion column. The thoughts expressed are those of the author. 
• See more stories on Insider’s business page.

With the passage of President Joe Biden’s COVID relief package containing new incentives for expanding Medicaid, states that have refused to deliver healthcare to millions of Americans are quickly running out of excuses.

For more than a decade, politicians in the deepest of red states have twisted themselves into knots trying to justify their denial of lifesaving care to essential workers, small business employees, farmers, and others who earn too much to qualify for Medicaid and too little to afford private insurance.

The preferred argument of Medicaid expansion opponents since the passage of the Affordable Care Act has been that expanding the program would simply cost their state too much — despite the fact that expansion states have always received at least $9 back from the federal government for every dollar they spent, a hefty 900% return on investment.

Now, with President Biden signing the COVID relief bill, the incentive for states to act has become even more generous. Outright budget savings are now being offered to any Medicaid expansion holdout that is willing to say yes to healthcare for essential workers, the return of state tax dollars, and increased economic activity for their local communities and businesses. Not to mention critical funding that can help keep rural hospitals open. 

‘It’s too expensive’ won’t cut it

Take Missouri, for example. Voters in that state approved Medicaid expansion last year, which is set to begin on July 1, 2021. The COVID relief package’s added funding for newly expanding states will save Missourians an estimated $1.7 billion over the next two years. Those savings alone will cover the state’s cost for Medicaid expansion for nearly a decade.

It’s not just Missouri that will benefit, either. Any state that hasn’t expanded Medicaid will get the same deal, receiving a 5% boost in the federal contribution to their overall Medicaid program for two years. The change means that moving forward it’s going to be impossible for politicians to credibly argue that Medicaid expansion is too expensive for a state to pursue.

The number of holdout states has already been shrinking in recent years as voters in red and purple states have rebelled repeatedly against political leaders who blocked the passage of the popular policy. Since 2017, Maine, Utah, Idaho, Nebraska, Oklahoma and the above-mentioned Missouri have all expanded Medicaid through ballot initiatives. 

A lot of attention has been given to the fact that a handful of Republican governors are still refusing to advance the issue, but it’s clear that voters across the political spectrum are on the side of Medicaid expansion. Pressure is building in the 12 holdout states, and it’s becoming impossible to ignore. If state politicians continue to block progress, these incentives make it even more likely that voters will pass new ballot measures in 2022.

The need for expansion 

Medicaid expansion remains the best way to get more people access to care and reduce racial healthcare disparities at this moment. For example, Black Americans are more likely to live in Southern states, many of which have not expanded Medicaid. In Mississippi alone, Black people make up 51% of those eligible under expansion, but only represent 38% of the state’s population.

Expanding the program has repeatedly led to a wide range of health outcome improvements like earlier cancer detection, greater access to diabetes medication, and increased access to mental health and addiction treatment. Medicaid also covers about four in 10 births in the US, and access to Medicaid coverage would allow more women to access prenatal and postpartum coverage. It’s estimated that an additional 141 infant lives could be saved each year if the remaining states expanded Medicaid. 

There are also numerous indirect benefits like reduced reliance on predatory loans and decreases in evictions, along with helping small businesses retain employees and employ a healthier workforce. 

The unwillingness of a handful of politicians and special interest groups to take action on this issue has never been about the facts, but in the past, opponents at least had a rationale to offer voters for their ideological opposition. Now, even that is gone.

Healthcare for 4 million people and 640,000 essential workers is at stake, and voters in red states are rightfully demanding that politicians put the made-up excuses aside. It’s time for the remaining holdout states to stop leaving Americans behind and start saving their constituents’ money at the same time.

Jonathan Schleifer is the executive director of The Fairness Project, a national organization that develops and supports Medicaid expansion and other social and economic justice ballot measures across the country.

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