In States That Won’t Expand Medicaid, Some Health Care Workers Can’t Even Get Insurance


Somewhat ironically, many of the direct-care workers living in states that haven’t accepted Obamacare’s optional Medicaid expansion can’t afford insurance benefits to ensure them the same quality of care given to the elderly and people with disabilities.

According to a new report released by the Paraprofessional Healthcare Institute (PHI) this week, more than 400,000 direct-care workers don’t have coverage, some of whom because they live in states that haven’t expanded Medicaid, which is a key tenet of the Affordable Care Act.

The report, titled “Too Sick to Care: Direct-Care Workers, Medicaid Expansion, and the Coverage Gap,” argues that the 21 states that have failed to expand Medicaid are missing an opportunity to improve work conditions and raise morale, so that home health workers can meet the needs of a growing patient base.

“In spite of all of the successes of the Affordable Care Act, making access to affordable health coverage possible for millions of people, nearly a half million hardworking direct-care workers who happen to live in states that have rejected Medicaid expansion are shut out of affordable coverage,” Abby Marquand, PHI’s director of policy research, wrote in a press release. “Direct-care workers are providing some of the most essential care to our nation’s elders and people with disabilities — experiencing high rates of on-the-job injuries, regularly exposed to communicable disease — and many can’t get the health care they need.”


Direct-care workers — many of whom are women, African American, or Latino — are less likely to get insurance through their employers, but they also struggle to earn enough money to purchase insurance on their own.

These health care professionals work closely with their patients in homes, nursing facilities, and hospitals for long periods of time. Unpredictable, part-time work hours reduce average pay, making median earnings for the nation’s more than 2 million home workers plummet to just $13,000 per year, according to a February PHI report.

The now-defunct Direct Care Alliance describes health care as a crucial benefit to the direct-care worker workforce, which suffers some of the nation’s highest rates of on-the-job injuries — caused by lifting and moving patients. Other workplace hazards include physical assault and threats, both of which can cause physical and mental trauma. A lack of provisions to address workplace safety also complicates efforts to create a stable environment for direct care workers. Health care advocates say such situations require time away from work and access to adequate medical services.

The Medicaid program, about to mark its 50th anniversary, has been of great significance to direct-care workers. Last year, the Obama Administration implemented rules that would ensure wage and hour protections and improvements for working conditions for direct-care workers. The rule would cost $6.8 million annually over a 10-year period, according to the U.S. Department of Labor — an investment that supporters said would reduce turnover and improve quality of care.

“The direct-care workforce is unique in the sense that Medicaid is paying the agencies that pay these workers,” Marquand told ThinkProgress. “States that recognize the value of this workforce can target Medicaid funds directly to worker wages and benefits and increase access to affordable health insurance.”


Under the ACA, states receive additional federal funding when they expand their Medicaid programs to include adults under 65 with income up to 133 percent of the federal poverty level. While a 2012 U.S. Supreme Court decision upheld the Medicaid portion of the ACA, Medicaid expansion now rested in state lawmakers’ hands. In the 21 states that have yet to expand Medicaid, low-income residents don’t have viable alternatives to coverage, especially if they fall within what’s known as the coverage gap — which means they have incomes above the Medicaid eligibility threshold but below the lower limit for Marketplace tax credits.

Even so, lawmakers in some states have been reluctant to expand coverage, due to a concern that they would shoulder costs, even with the Obama Administration’s assurances that their expenditures would be covered. Those states have spent less than expected on Medicaid benefits because they aren’t adding as many patients to the roll. Nearly 4 million people — many of whom hail from African-American and Latino communities in the South — don’t have access to affordable coverage because they fall within the coverage gap.

But all of that could soon change in some states. For instance, Democrats in South Carolina energized by the removal of the Confederate flag from the Statehouse grounds renewed a push to pass Medicaid expansion for nearly 200,000 adults. If it comes to fruition, that victory would follow similar acts that transpired in other states. Last month, Alaska Governor Bill Walker used his executive might to expand Medicaid. Montana Governor Steve Bullock extended Medicaid coverage to 45,000 residents when he signed a bill that received bipartisan support.

“You see a lot more conversations happening. States are grappling with the significance of having a large population of people living in poverty without access to health insurance,” Marquand said. “I’m hopeful that some form of Medicaid expansion could happen in those 21 states. It’s not about expanding government programs for the sake of it but ensuring all people have access to affordable health care, especially health care workers.”