Letter to the Hon. Charles S. Schumer, Majority Leader United States Senate, the Hon. Nancy Pelosi, Speaker US House of Representatives - - Ruiz Calls for Biden Administration to Address Medicaid Coverage Gap with American Families Plan

Letter

Dear Majority Leader Schumer and Madam Speaker Pelosi,

We, the undersigned members of the Congressional Black Caucus, the Congressional Hispanic
Caucus, and the Congressional Asian Pacific American Caucus together write to urge you to close
the Medicaid "coverage gap" in the forthcoming American Families Plan. The coverage gap leaves
over two million Americans with incomes below the poverty line uninsured and without any
pathway to health coverage and almost two million more uninsured people with incomes between
100 and 138 percent of the poverty line who would be eligible if their states expanded.1[1] Closing this gap is one of the single most important steps we can take to reduce health inequities across the United States, as almost 60 percent of people affected by the coverage gap are Black, Hispanic, Asian, of Pacific Islander.2[2] Additionally, much of the affected population lives in the South, where state governments have failed to provide basic health coverage for their residents. It is unacceptable for the federal government to continue to allow some states to deny basic health coverage to these uninsured and underinsured Americans.

Medicaid provides comprehensive, affordable, quality health insurance specifically designed for
low-income individuals. We urge you to ensure that, regardless of state political decisions or
immigration status, everyone eligible for Medicaid expansion is finally able to access the
protections of Medicaid. We were pleased that the American Rescue Plan includes a bold new incentive to encourage states to finally do the right thing and expand Medicaid. Numerous researchers have repeatedly established the value of Medicaid expansion. Over 600
studies reviewed by the Kaiser Family Foundation show that Medicaid expansion has wide-ranging
benefits, including reducing overall mortality, as well as mortality associated with cancer, cardiovascular disease, and liver disease.3[3] It has decreased racial disparities in coverage rates,
affordability of care, and in some health outcomes- including maternal and infant mortality.

Closing the coverage gap would have a significant impact in addressing the Black maternal health
crisis, which was the subject of a September 9, 2019 hearing of the House Energy and Commerce
Committee, and a May 6, 2021 hearing of the House Committee on Oversight and Reform. To
prevent complications and ensure a healthy pregnancy and birth, people need health coverage
before they become pregnant and throughout the entirety of their pregnancy and postpartum
period. Currently, women in the coverage gap are not eligible to receive care under Medicaid until
their pregnancy begins. More than half of people in the coverage gap are women, including large
numbers of Black, Hispanic, and Native Hawaiian or other Pacific Islander women, and do not
have a pathway to coverage until eligibility is established based on pregnancy.4[4]
This means these women do not have access to vital maternal health care in those critical early weeks and months of pregnancy. This has become even more critical during the COVID-19 pandemic as Hispanic women make up the largest number of pregnant women with COVID-19 and are at increased risk of adverse pregnancy outcomes.5[5]

The Affordable Care Act (ACA) intended for Medicaid expansion to be available to all people
with low incomes regardless of where they live. In fact, the ACA fully accounted for the
cost of that expansion, but the Supreme Court decision in NFIB v. Sebelius left decisions of expansion up to the states. Despite the evidence of the lifesaving care provided by Medicaid expansion, 12 state governments still refuse to expand, even with the significant financial incentives provided in the American Rescue Plan. These states additionally lose out on the fiscal benefits of expansion, which research shows produces net budget saving. These states' refusal to expand means residents of those states are denied the far-reaching benefits of expansion. In fact, a landmark study found that in states refusing to expand Medicaid, 15,600 died prematurely from 2014 to 2017, and it is likely that premature deaths are trending upward.6[6]

To advance the goals of Medicaid and the ACA, it is also critical to prioritize the elimination of
disparities in Medicaid funding for Puerto Rico and U.S. territories, provide access to Medicaid
and the Children's Health Insurance Program (CHIP) to lawfully present immigrants without a
five-ear waiting period, and grant access to Medicaid and marketplace coverage to Deferred Action for Childhood Arrivals (DACA) recipients. Specifically, we request that you work with HHS, so the agency will repeal 45 C.F.R. § 152.2(8), which excludes DACA recipients from the definition of "lawfully present" and, consequently from benefits under the ACA. As a result of current regulations and guidance, DACA recipients cannot:
a)Obtain comprehensive health insurance under Medicaid or the Children's Health Insurance Program (CHIP) in most states
b)Receive federal premium tax credits to make private health insurance affordable in the marketplace (even though DACA recipients still file and pay federal taxes); or
c)Purchase health insurance in the ACA's health insurance marketplace, even at full cost using their own funds;

Recovery legislation presents a unique, historic opportunity to close the gaps in coverage for the
millions of people in the Medicaid coverage gap, people who rely on Medicaid in
Puerto Rico and the territories, and DACA recipients. We must take advantage of this once-in-a-generation opportunity to bring affordable health care to all Americans. There are various ways to close these gaps and bring lifesaving coverage to millions of Americans --through enrollment in a
public option plan offered in the marketplace as set forth in President Biden's campaign plan, a
federally-administered Medicaid plan, through enrollment in marketplace plans adjusted to align
with Medicaid for those in the 12 non-expansion states, by eliminating disparities in Medicaid
funding for Puerto Rico and the territories, and by granting access to ACA benefits for DACA
recipients. Regardless, coverage should be as similar as possible to Medicaid to ensure that people in the coverage gap can experience the robust, positive impact of Medicaid.

The coronavirus pandemic has only illuminated the far-reaching, fatal consequences of inadequate access to health care. Addressing the Medicaid coverage gap is critical both i
n correcting decades of unacceptable and unjust denial of health care coverage to underserved and minority populations throughout the United States and in protecting our nation from future pandemics. Simply put, it is imperative that Congress and the Biden-Harris Administration enact policies to close the coverage gap to significantly reduce racial health disparities and ensure all Americans have access to basic health care. We look forward to working with you to reduce racial disparities associated with the coverage gap and finally realize the promise of the Affordable Care Act for all Americans, regardless of where they live.

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