Ensure Health Care for All

“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”




When a child is injured or a loved one is suffering from a serious illness, no one wants to think about co-pays and deductibles. We want compassionate, effective medical care, delivered quickly and accessibly. We know that people, families, communities, and our nation thrive when good health is a public priority. The Affordable Care Act was an historic achievement to provide health insurance to a record number of uninsured Americans. Yet even if the Affordable Care Act were fully implemented, nearly 30 million people would remain uninsured, and out-of-pocket medical costs could lead to financial ruin for many people. At the same time, ideologically driven politicians continue to threaten recent gains in access to health care.

Most Americans still worry about the availability and affordability of health care.249 America’s fragmented and complex health care system makes us a global outlier; we are the only industrialized nation that fails to deliver health care to all of its people. America also has a growing under-insurance problem. People may have insurance, yet their sky-high health plan premiums, copays, and deductibles cause financial stress or result in patients missing necessary treatment. Medical debt remains the leading cause of personal bankruptcy in the United States.250 According to the Kaiser Family Foundation, more than a quarter of Americans struggle to pay their medical bills.251 Our system treats health care as a commodity available based on one’s ability to pay, worsening existing health disparities by class and race.           

People of color, undocumented immigrants, and people with low incomes have higher rates of disease and mortality, and suffer disproportionately under our current health coverage scheme. African Americans are 77 percent more likely than white Americans to develop diabetes.252 People of color run 2 to 4 times the risk of reaching end-stage renal disease than white people.253 Racial disparities are particularly acute for pregnant women and infants: Because African-American mothers are far less likely to receive prenatal care than white mothers and the care they do receive is likely to be lower quality, the infant mortality rate for black babies is more than twice as high as for white babies, and black mothers are more than 3 times more likely to die in childbirth than white mothers.254  While many structural factors contribute to worse health care outcomes for patients of color, our current for-profit system adds to disparities by creating both financial obstacles and barriers to accessing a doctor. Politicians worsen this situation by refusing to allow undocumented patients to purchase subsidized Obamacare plans and to obtain Medicaid coverage. This not only burdens immigrant health, but also weighs down our inefficient health care delivery system.

States must take steps to build upon the gains of the Affordable Care Act and expand health care access and coverage. In the 18 states that have not yet expanded eligibility for Medicaid coverage, 2.6 million adults fall within a coverage gap where they earn too much to qualify for traditional Medicaid yet too little to be eligible for tax credits that would help them pay for private insurance coverage.255 Expanding Medicaid eligibility, which comes at little cost to the state, is the critical first step for states to increase health care access.



37% of Virginia voters cited health care as their most important issue after the November 2017 election. 256

74% of Americans hold a favorable view of Medicaid, including 73% of adults in states that have not yet expanded Medicaid eligibility.257

67% of Americans say Medicaid “works well” for the people it covers in their state.258



Expand health insurance coverage and access to health care for all state residents. States should consider the following steps:

  • Expand Medicaid coverage. Currently 32 states and the District of Columbia have expanded Medicaid eligibility to cover non-elderly adults with incomes below 138 percent of the federal poverty level.259 The Affordable Care Act provides federal funding for the vast majority of the cost of Medicaid expansion. States that have not yet expanded Medicaid eligibility should immediately act to do so.
  • Reject work requirements and other restrictions on Medicaid eligibility. A number of states have applied for federal waivers in order to impose work requirements on Medicaid recipients.260 Imposing such restrictions does not increase access to employment among Medicaid recipients (the vast majority of whom already work, are sick or disabled, or are family caregivers) yet puts an estimated 6.3 million Americans in danger of losing health coverage as they scramble to document their conditions or risk falling through new gaps in the program.261 States should reject any effort to limit Medicaid enrollment.
  • Establish a Basic Health Program. The Affordable Care Act gives states the option to implement a Basic Health Program to cover residents with incomes between 133 percent and 200 percent of the federal poverty level. 262 The program provides continuity of care and coverage to people whose incomes fluctuate. In addition, green card holders and other lawfully present non-citizens who are excluded from Medicaid coverage are eligible for the program. Currently Minnesota and New York have established Basic Health Programs, providing affordable, comprehensive coverage to 800,000 people. Coverage under the program must include the essential benefits specified by Affordable Care Act. Monthly insurance premiums and out-of-pocket costs cannot exceed what they would be for plans purchased through the Affordable Care Act marketplace, and in practice they are often considerably lower. New York and Minnesota recently sued the federal government to maintain federal funding for the program, which reimburses states for the vast majority of costs.263
  • Increase support for community health centers. Community health centers are the most significant source of comprehensive primary care for medically underserved communities across the United States. They provide affordable primary care to over 27 million people, regardless of insurance coverage or ability to pay.264 Although a majority of community health center revenues come from insurance payments and federal grants, state and local grants and contracts made up approximately 11 percent of community health center revenue in 2015.265 Increasing state support would expand the populations health centers can serve.
  • Implement all-payer rate setting. Through a Medicare waiver, the state of Maryland has the authority to regulate the rates that hospitals charge for their services. Maryland mandates that hospitals charge the same rate for any given service or provider to all patients, regardless of what type of insurance patients have. Maryland has further controlled health care costs by adopting global budgets, which incentivize hospital systems to keep patients healthy. As a result of these systems, Maryland has limited the growth in hospital costs for all patients.266 In addition to cost containment, Maryland’s system is significant because it lays the groundwork for a single-payer universal health care system. Maryland is currently seeking to expand the system beyond hospitals to other health care expenditures. Other states should explore seeking a waiver to emulate Maryland’s successful program.



A number of states are exploring the potential for universal health care systems, which would replace the private health insurance industry with single-payer, publicly managed insurance providing coverage to all state residents. While regulatory, fiscal, and political hurdles remain, policymakers and advocates who are determined build state-level single-payer systems are making important progress.



  • We all thrive when good health is a public priority. When a child is injured or a loved one is suffering from a serious illness, no one wants to think about co-pays and deductibles. We want compassionate, effective medical care, delivered quickly and accessibly. The Affordable Care Act brought meaningful reforms to our system. Now we must work toward making health care access a reality for all Americans.
  • No one should struggle with debt to get the care they need. Medical debt is still the leading cause of personal bankruptcy in the United States, and more than 1 in 4 Americans struggle to pay their medical bills. People may have insurance, but health plan premiums, copays, and deductibles are so high that they cause financial stress or result in patients missing necessary treatment. Americans continue to die because they lack affordable health coverage. We need to ensure people can get the health care they need without going broke.



  • States that expanded Medicaid had significantly fewer residents without insurance as a result, with the greatest increases in insurance coverage in rural areas and among vulnerable populations such as young adults, people with HIV, veterans, and children.267
  • By making health care more affordable, Medicaid expansion increases financial security for struggling families. For example, in Ohio, the percentage of expansion enrollees with medical debt fell by nearly half since enrolling in Medicaid. Previously uninsured prescription drug users who gained Medicaid coverage in 2014 saw, on average, a $205 reduction in annual out-of-pocket spending.268
  • Medicaid expansion saves lives. For example, expanding Medicaid was associated with a lower risk of death among cardiac surgery patients.269
  • There were no significant increases in state spending due to Medicaid expansion and some states have saved money. Louisiana reported that Medicaid expansion saved the state $199 million in its 2017 fiscal year, due in part to changes in federal reimbursement rates.270
  • Maryland’s all-payer rate regulation produces large savings for Medicare-participating hospitals compared to those operating in other states. From 2013 through August 2016, the hospital spending growth rate underlying Maryland’s savings was more than 4 percent below the national growth rate. Maryland state hospitals saved more than $429 million for Medicare.271
  • New York’s plan under the Basic Health Program provides low- or no-cost health coverage to 700,000 low-income people. Participants pay between $0 and $20 for their monthly premiums and can purchase a health plan at any time during the year.272





  1. Healthcare System: Gallup Historical Trends, Gallup, March 1-5 2017, http://news.gallup.com/poll/4708/healthcare-system.aspx. 
  2. Maurie Backman, “This is the No. 1 Reason People File for Bankruptcy,” The Motley Fool, May 5, 2017, https://www.usatoday.com/story/money/personalfinance/2017/05/05/this-is-....
  3. Liz Hamel, Mira Norton, Karen Pollitz, Larry Levitt, Gary Claxton and Mollyann Brodie, The Burden of Medical Debt: Results from the Kaiser Family Foundation/New York Times Medical Bills Survey, Kaiser Family Foundation, January 5, 2016. https://www.kff.org/report-section/the-burden-of-medical-debt-section-1-....
  4. Edward A. Chow, MD, Henry Foster, MD, Victor Gonzalez, MD and LaShawn McIver, MD, MPH, “The Disparate Impact of Diabetes on Racial/Ethnic Minority Populations,” Clinical Diabetes 2012 Jul; 30(3): 130-133. https://doi.org/10.2337/diaclin.30.3.130.
  5. Robin L. Kelly Ph.D., “The 2015 Kelly Report: Health Disparities in America,” Congresswoman Robin L. Kelly, September 18, 2017, https://robinkelly.house.gov/sites/robinkelly.house.gov/files/2015 Kelly Report.pdf.
  6. U.S. Center for Disease Control and Prevention, “Pregnancy Mortality Surveillance System,” November 9, 2007, https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html; U.S. Department of Health and Human Services, Office of Minority Health, “Infant Mortality and African Americans,” November 9, 2007,   https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=23. 
  7. The Henry J. Kaiser Family Foundation, Medicaid Pocket Primer, June 9, 2017, https://www.kff.org/medicaid/fact-sheet/medicaid-pocket-primer/.
  8. NBC News, “Early Exit Polls: Health Care Most Important Issue for Virginia Voters,” National Broadcasting Network, November 7, 2017,  https://www.nbcnews.com/card/early-exit-polls-health-care-most-important....
  9. 10 Charts About Public Opinion on Medicaid Kaiser Family Foundation, June 27, 2017 https://www.kff.org/medicaid/poll-finding/data-note-10-charts-about-publ....
  10. Ibid.
  11. For a list of states as of January 2018, see: Status of State Action on the Medicaid Expansion Decision, The Henry J. Kaiser Family Foundation, January 18, 2018, https://www.kff.org/health-reform/state-indicator/state-activity-around-....
  12. MaryBeth Musumeci, Rachel Garfield, and Robin Rudowitz, Medicaid and Work Requirements: New Guidance, State Waiver Details and Key Issues, Henry J. Kaiser Family Foundation, January 2018, https://www.kff.org/medicaid/issue-brief/medicaid-and-work-requirements-....
  13. Katherine Gallagher Robbins and Rachel West, Trump’s Medicaid Work Requirements Could Put At Least 6.3 Million Americans at Risk of Losing Health Care, Center for American Progress, January 2018. https://www.americanprogress.org/issues/poverty/news/2018/01/12/444953/t...
  14. Medicaid.Gov, “Basic Health Program” Centers for Medicare and Medicaid Services, January 2017, https://www.medicaid.gov/basic-health-program/index.html.
  15. Michelle Andrews, “Trump’s Subsidies Cut Threatens Basic Health Programs in 2 States,” Governing, February 9, 2018, http://www.governing.com/topics/health-human-services/khn-minnesota-new-....
  16. United States Health Center Fact Sheet, National Association of Community Health Centers, 2018, http://www.nachc.org/wp-content/uploads/2018/01/US_18a.pdf 
  17. Julia Paradise, et. al., Community Health Centers: Recent Growth and the Role of the ACA, Henry J. Kaiser Family Foundation, January 2017, https://www.kff.org/report-section/community-health-centers-recent-growt...
  18. Nelson Sabatini, et. al., “Maryland’s All-Payer Model—Achievements, Challenges, And Next Steps” Health Affairs, January 31, 2017, https://www.healthaffairs.org/do/10.1377/hblog20170131.058550/full/.
  19. Larisa Antonisse et. al., The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review, Henry J. Kaiser Family Foundation, September 2017, https://www.kff.org/medicaid/issue-brief/the-effects-of-medicaid-expansi...
  20. Ibid.
  21. Ibid.
  22. Ibid.
  23. Sabatini, “Maryland’s All-Payer Model.”
  24. Eric T. Schneiderman, “In Defense Of New York State’s ‘Essential Plan,’ We’re Suing The Trump Administration,” Health Affairs, February 7, 2018, https://www.healthaffairs.org/do/10.1377/hblog20180206.483547/full/.