KFF: 9 in 10 people who fall into ACA ‘coverage gap’ live in Southern states

Affordable Care Act highlighted
A new Kaiser Family Foundation Study dives into the ACA's "coverage gap." (Getty/Ellenmck)

The majority of people who fall into the ACA’s “coverage gap”—or, are not eligible for Medicaid or tax credits on the exchanges—live in one of four nonexpansion states, according to a new study.

The Kaiser Family Foundation analyzed the people who fall into that gap by having incomes too high for Medicaid but too low for tax credits to purchase Affordable Care Act marketplaces, and found that of the 2.5 million who fit that description, 9 in 10 live in a Southern state.

Specifically, about 68% of these people live in either Texas, Florida, Georgia or North Carolina, the study found. Nearly one-third are Texas residents, with 769,000 people in the coverage gap residing there.


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The trends reflects long-standing historical disparities in healthcare access, Rachel Garfield, senior researcher at KFF and one of the report’s authors, told FierceHealthcare.

“I think the key takeaway is just how many people are left in this coverage gap situation, that it’s 2.5 million people left without an affordable coverage option under the ACA because of their state’s decision not to expand Medicaid,” Garfield said.

RELATED: The impact of ‘partial’ Medicaid expansion on coverage

In addition to implications for these historical poverty trends, the study also found that the coverage gap can worsen existing racial and ethnic disparities in access to care.

A significant number of people of color live in the South, and they’re especially vulnerable to falling into the coverage gap, according to the study. Blacks are particularly at risk, the study found.

“It means that people of color are more likely to fall into coverage gaps than whites,” Garfield said.

What’s the solution? For states that are staunchly opposed to expanding Medicaid and thus catching these people before they fall through the cracks, there’s limited recourse, Garfield said.

RELATED: Voter-backed Medicaid expansion hit snags in 4 states. Where are they now?

Additional investment in community clinics and charity care can help cover the costs when people do need care, she said, but they’re not a viable alternative to coverage.

Some states that have so far resisted Medicaid expansion are now exploring a “partial” approach, which would expand the program to fewer people than allowed under the ACA but still boosting enrollment.

Garfield said that would still leave many people in the coverage gap or would push them into exchange plans that may not meet their needs. She also said that Medicaid expansion plans that include tight guardrails, such as work requirements, may also pose a risk to this population, especially as many are already working in low-wage jobs that don’t include health coverage.

“The idea that they should just get coverage through their jobs is not the reality of the current world,” Garfield said.

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