What are some low-income health insurance plans and carriers available through Medicaid or the Affordable Care Act (ACA) marketplace?

Low-Income Health Insurance Plans and Carriers

The primary low-income health insurance options in the United States are Medicaid and subsidized Marketplace plans through the Affordable Care Act (ACA), with Medicaid being the superior option for coverage and enrollment when available. 1

Primary Coverage Options

Medicaid

• Medicaid is the primary mechanism for extending health coverage to low-income individuals without health insurance 1
• Covers approximately 12% of all adults of childbearing age and 37% of low-income adults in that age group 1
• Provides comprehensive coverage without premiums and deductibles in most states 2
• Has been demonstrated to be effective in improving access to health care for low-income populations 1
• Enrollment in Medicaid is 81-89% higher than Marketplace enrollment among those near the eligibility threshold, demonstrating its superior accessibility 2

ACA Marketplace Plans

• Provides subsidized private insurance coverage for individuals with incomes above Medicaid eligibility thresholds 1
• Requires premium contributions and cost-sharing, even with federal subsidies at lower incomes 2
• Marketplace enrollment drops off dramatically (81-89%) compared to Medicaid just above the 138% federal poverty level threshold, particularly among younger adults aged 26-44 years 2
• From 2009 to 2016, insurance coverage among low-income individuals with diabetes increased from 67% to 94% following ACA implementation 1

State Children's Health Insurance Program (CHIP)

• Covers poor children and families alongside Medicaid 1
• Part of the historical framework established in 1965 for covering vulnerable populations 1

Medicare

• Covers virtually all Americans 65 years and older, with coverage remaining stable at 99.5% 1
• Also covers younger individuals who are medically disabled 1

Critical Coverage Gaps and Geographic Disparities

Medicaid Expansion Status

• 12 states have not expanded Medicaid eligibility under the ACA, leaving substantial numbers of low-income individuals underinsured or uninsured 1
• In 2019,31 million people (9.5% of the U.S. population) remained uninsured despite ACA provisions 1
• 97% of uninsured individuals live in the southern United States: 35% in Texas, 19% in Florida, 12% in Georgia, and 10% in North Carolina 1
• Low-income individuals in the coverage gap are more likely to be Black 1

Partial Expansion Limitations

• Wisconsin's partial expansion (setting Medicaid eligibility at 100% of poverty level instead of 138%) demonstrated that less than one-third of adults who lost Medicaid eligibility obtained commercial coverage, with many returning to Medicaid 3
• This approach resulted in overall coverage gains similar to non-expansion states, demonstrating the difficulty of relying on Marketplace coverage for the near-poor 3

Family Planning Waivers

• Since 1995,22 states have used federal waiver authority to expand family planning services to individuals who don't otherwise qualify for Medicaid 1
• These waivers offer coverage to those who lose coverage after childbirth or starting employment, or based on income status 1
• Evaluations show substantial savings to federal and state governments, though more comprehensive coverage would yield greater prevention benefits 1

Clinical Implications for Health Outcomes

Impact on Morbidity and Mortality

• Uninsured individuals with diabetes are more than twice as likely to have HbA1c >9% (indicating poor glucose control) compared to insured individuals 1
• Poor diabetes control and poor blood pressure control are significantly more frequent among uninsured individuals 1
• Improvements in health outcomes, including survival and reductions in health disparities, have been demonstrated for older adults entering the Medicare program 1

Access Differences Between Coverage Types

• Adults in Medicaid expansion states experienced larger reductions in out-of-pocket spending compared to those in non-expansion states with Marketplace coverage 4
• However, adults in expansion states faced greater difficulty accessing physician care relative to those in non-expansion states 4
• Both groups experienced similar increases in having a usual source of care and primary care visits, and similar reductions in delayed medical care due to cost 4

Public Perception and Support

• Nearly 80% of low-income adults in Arkansas, Kentucky, and Texas favored Medicaid expansion 5
• Approximately two-thirds of uninsured respondents planned to apply for either Medicaid or subsidized private coverage 5
• Most viewed having Medicaid as better than being uninsured and at least as good as private insurance in overall quality and affordability 5

Common Pitfalls to Avoid

• Don't assume Marketplace plans are equivalent to Medicaid for low-income populations - enrollment rates are dramatically lower and cost-sharing requirements create barriers 2
• Don't overlook state-specific Medicaid expansion status - eligibility varies dramatically by state, with 12 states not participating in expansion 1
• Don't forget about family planning waivers - 22 states offer expanded family planning services that may cover individuals who don't qualify for standard Medicaid 1
• Be aware that awareness of state expansion plans is low among eligible populations - proactive outreach and education are necessary 5