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Nearly a Half Million Paid Caregivers Shut Out of Medicaid because States Have Rejected Medicaid Expansion, a New PHI Analysis Finds

July 27, 2015

Direct-Care Workers Living in Southern States, and Younger, Black, and Latino Workers Are Disproportionally Affected When States Opt Out of Medicaid Expansion

Bronx, NY — Nearly a half million of the nation's paid caregivers have household incomes below 138 percent of the Federal Poverty Level (FPL) but remain ineligible for Medicaid because they reside in one of the states that has refused federal funds to expand Medicaid eligibility, found a new study by PHI, the nation's leading authority on the direct-care workforce.

The Affordable Care Act offers states incentives to expand Medicaid eligibility to all adults living in households with incomes below 138 percent FPL. The federal government will pay the full cost of expansion through 2016, and then will provide a 90 percent federal match after that. Nonetheless, 21 states have chosen not to expand their programs.

"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," said PHI Director of Policy Research Abby Marquand, who conducted the study and authored the report, "Too Sick to Care: Direct-Care Workers, Medicaid Expansion, and the Coverage Gap," for Medicaid's 50th anniversary.

"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 because they are falling into the 'coverage gap,'" Marquand said.

In states that have not expanded Medicaid coverage, most adults, particularly those without dependent children, are excluded from the program. If their household incomes are below 100 percent FPL, they are also ineligible for subsidies on the state health care market exchanges. About 300,000 direct-care workers — home health aides, personal care aides, and nursing assistants — fall into this "coverage gap." They have no new coverage options under the Affordable Care Act.

Texas has the largest number of paid caregivers in the coverage gap, with 83,000, followed by North Carolina, where 29,000 direct-care workers fall into the gap. Florida and Missouri also have tens of thousands of caregivers in the coverage gap.

State decisions not to expand Medicaid eligibility disproportionately affect direct-care workers living in Southern states. Of the 1.2 million direct-care workers in non-expansion states, nearly four out of five (78 percent) live in the South, where of 17 states and the District of Columbia only 6 have expanded Medicaid eligibility.

Younger direct-care workers are also disproportionately affected by state decisions not to expand Medicaid, the analysis shows. One third of direct-care workers under age 55 live in households with incomes below 138 FPL compared to one quarter of workers aged 55 and over.

The decision not to expand Medicaid eligibility also has a disproportionate impact on blacks and Latinos, who comprise 35 percent and 17 percent, respectively, of direct-care workers in households with incomes below 138 percent FPL, reports Marquand. Among direct-care workers with incomes over 138 percent of FPL, more than half are white and only 40 percent are black or Latino.

In 2015, the FPL was $11,770 for an individual and $20,090 for a family of three.

There are 3.4 million direct-care workers across the nation who provide long-term care to elders and people with disabilities living in private homes, community settings, and nursing homes, and that number is projected to grow to 5 million by 2022. Direct-care workers across all settings earn an average of $10.85 an hour. Part-time hours, typical of these occupations, further reduce median income to $16,100 a year. One in four of all direct-care workers was uninsured in 2013.

In the 29 states (and the District of Columbia) that have expanded Medicaid eligibility, 667,000 direct-care workers meet the income eligibility requirements, providing them with an affordable health coverage option. Marquand recommends that every state expand eligibility to ensure that direct-care workers, along with millions of other low-income people, can access health coverage.

"Direct-care jobs need to be made more attractive if we, as a nation, plan to meet the growing demand for this essential workforce and the critical long-term services and supports they provide. Improving wages and ensuring access to affordable health coverage would be a very good start," Marquand said.

Additional recommendations, including how to make employer-sponsored coverage more accessible to direct-care workers, are detailed in "Too Sick to Care: Direct-Care Workers, Medicaid Expansion and the Coverage Gap."

For more information on the direct-care workforce, see "FACTS 3 — Who Are Direct-Care Workers?" and visit the PHI State Data Center.

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PHI (Paraprofessional Healthcare Institute) works to transform eldercare and disability services, fostering dignity, respect, and independence — for all who receive care, and all who provide it. The nation's leading authority on the direct-care workforce, PHI promotes quality direct-care jobs as the foundation for quality care (

Deane Beebe; PHI Media Relations Director; 718-928-2033 (office); 646-285-1039 (cell) 

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