2021’s States with the Most & Least Medicaid Coverage

Medicaid provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults and people with disabilities. There were 77,306,714 individuals were enrolled in Medicaid and CHIP in the 51 states that reported enrollment data for September 2020. The Biden administration is planning to remove the Trump administration health policy goal of requiring people to work to receive Medicaid coverage.

With the Biden administration reversing work requirements for Medicaid coverage and the COVID-19 pandemic highlighting the importance of good healthcare, the personal finance website WalletHub today released its report on 2021’s States with the Most & Least Medicaid Coverage.

In order to identify which states rely most and least on Medicaid, they compared the 50 states across 12 metrics, ranging from total Medicaid spending per low-income population to adult care quality to the eligibility level of children.

Key Stats

• Massachusetts has the highest total Medicaid spending per low-income population, $13,416, which is 3.9 times higher than in Georgia, the state with the lowest at $3,483.
• Rhode Island has the highest total Medicaid enrollment per low-income population, 1.24, which is 3.4 times higher than in Wyoming, the state with the lowest at 0.37.
• Vermont has the highest share of individuals diagnosed with major depression who were treated with and remained on antidepressant medication for 12 weeks, 73.80 percent, which is 1.9 times higher than in Mississippi, the state with the lowest at 39.20 percent.
• Missouri has the highest total Medicaid spending as a share of the total state budget, 39.02 percent, which is 2.8 times higher than in Wyoming, the state with the lowest at 13.83 percent.

WalletHub Q & A

Nationally, there are two million poor uninsured adults that fall into the “coverage gap” resulting from state decisions not to expand Medicaid. What are the best options to consider for an individual that does not qualify for Medicaid?

“The coverage gap is probably the most detrimental, unintended consequence of the ACA, as driven by states’ decisions not to expand Medicaid,” said Megan B. Cole, PhD, Boston University School of Public Health. “If you are a childless adult, happen to live in a non-expansion state, and are under 100% of the federal poverty level, then there really are not any coverage options. You do not make enough income to qualify for subsidized private coverage through the Marketplace and you also do not qualify for Medicaid. For that individual, there really are not any great options. You could purchase a full-price plan from the Marketplace, but this would be cost-prohibitive. Even if you have an employer who offers you coverage, the premiums alone could consume most of your paycheck. It is a huge injustice.”

“There are very limited options of charity care, community health centers mostly for primary care, and visiting the ER,” said Adam Searing, Georgetown University. “Options like this often involve large bills for the uninsured individual and are no substitute for comprehensive health coverage.”

Given the fact that a growing number of states seek to establish work requirements in their Medicaid programs, what is your opinion on this matter and how does it affect the disadvantaged population?

“There is no evidence that Medicaid work requirements are effective in any capacity,” said Jamila Michener, Cornell University. “Most Medicaid beneficiaries are already working. Those who are not working are often engaged in other important activities that should be supported: informal care work for elderly or disabled family members, childcare, and other forms of labor that are unpaid but important. The main function of Medicaid work requirements is to create a barrier to accessing Medicaid. When work requirements are implemented, people lose access. This runs counter to the statutory purpose of Medicaid. As a result, Medicaid work requirements have been stalled and invalidated in the courts. Now they are being rolled back by the Biden administration. On top of all that, there is evidence to suggest that work requirements (in general) are racially inequitable, disproportionately harming Black women. Work requirements are not an equitable or sustainable policy.”

“The establishment of work requirements is a complicated issue that was encouraged in the Trump administration,” said Karoline Mortensen, PhD, University of Miami. “The Biden administration does not support work requirements, as they go against the objective of Medicaid, which is to provide health insurance coverage to vulnerable populations. Although several states have approved waivers to allow work requirements, to my knowledge there are no states with active enforcement of a work requirement waiver. States have struggled with developing systems of determining work status and enforcement, and the issue is before the Supreme Court. The evidence shows that most Medicaid enrollees who can work were doing so before the pandemic and will likely struggle to find employment during the pandemic. I have not found an academic study that has found positive benefits of the work requirement policy. They can reduce insurance and access to care for vulnerable populations.”

Are states that have expanded Medicaid better positioned against COVID-19 and a recession?

“Yes, a preexisting wide-ranging mechanism is in place to provide services, such as Medicaid, it will greatly improve the ability to address a public emergency,” said Christine S. Brennan, PhD, RN, NP-BC, Louisiana State University Health Sciences Center New Orleans. “The structure is in place to implement policies. The issue with COVID was that the US did not respond appropriately to COVID at the beginning, Medicaid, or no Medicaid. The lack of screening early in the epidemic was pathetic and was a major contributor to the resulting economic recession. We should have had a widespread, easy access screening system so we could have, to some extent, this tack was a governmental decision, nothing to do with Medicaid. Since then anything to do with COVID has been covered, insurance or no insurance, through direct state or federal reimbursement. Having more people utilizing the health care system, knowing how to use the system, before the PHE was useful. Having 90% of the population with insurance, thus increasing access to the health care system helped people knew how to “navigate” the system to some extent. It would have been really good if they all had already established a good relationship with a Primary care provider who they trusted and knew how to communicate with. Having EMR’s that could go to the Telehealth system was also key.”

“Yes. Although hospitals received relief under the CARES Act in 2020, these funds were not equally distributed across hospitals,” said Colleen M. Grogan, University of Chicago. “Our study of the allocation of Provider Relief Funds shows that safety-net hospitals predominantly serving vulnerable populations and communities with a high proportion of people of color received substantially less than hospitals in strong financial positions serving communities with a high proportion of privately insured. That means those safety-net hospitals in non-expansion states are even worse off since the Provider Relief Funds made no adjustments for the fact that safety-net hospitals in these states will have a high proportion of uninsured patients. (See Grogan, Lin, Gusmano, 2021 attached).”

To view the full report and your state’s rank, please visit:

https://wallethub.com/edu/states-with-the-most-and-least-medicaid-coverage/71573