Follow the money.
The United States spends more on healthcare than any country on Earth: about $5.6 trillion in 2025 alone. Other wealthy countries spend about half as much per person.
And still, millions of Americans can’t afford to see a doctor. It’s not that medicine doesn’t exist. It’s that the system — our system — decides who deserves access and who does not.
In 2023, more than 25 million Americans lacked health insurance. Some are excluded by immigration policy. Others fall into bureaucratic limbo. But inside this larger national failure lies a smaller, uglier truth: 1.4 million adults in 10 states are uninsured because their state governments have chosen not to cover them.
They are trapped in what policy experts call the Medicaid coverage gap. The solution has been obvious for over a decade: expand Medicaid, cover the poor and save lives.
Yet 10 states still refuse.
At this point, the coverage gap is no longer an oversight. It’s not even about budgets. It is a political choice, repeated year after year by elected officials who have decided to leave their poorest constituents without care.
Let’s see why.
Before the Affordable Care Act (ACA), Medicaid was never designed to insure all poor adults. The program primarily covered specific groups such as children, pregnant women, some very low-income parents, seniors and people with disabilities. Many poor adults without dependent children remained ineligible, regardless of how little they earned.
The ACA tried to address this problem by expanding Medicaid eligibility to nearly all adults earning up to 138% of the federal poverty level (FPL), which was $21,597 for an individual in 2025. For people earning slightly more, the law created marketplace subsidies to help low- and moderate-income Americans with incomes between 100% and 400% of the FPL afford insurance.
What went wrong?
In NFIB v. Sebelius, the Supreme Court ruled that Medicaid expansion had to be optional for states. While the ACA intended to create a nationwide floor of coverage, it instead became a state-by-state political gamble. As of February 2026, 10 states still have not expanded Medicaid.
In these non-expansion states, adults living below the poverty line often qualify for neither Medicaid nor marketplace subsidies. They earn too much for their state’s limited Medicaid program but too little to receive financial help through insurance subsidies. That is the gap.
Let’s not pretend the solution is some great mystery. We know exactly what could close the coverage gap.
One option would restore the ACA’s original incentive: the federal government covering 100% of the cost for the first three years of expansion, before falling to the still-generous 90% federal match. Essentially, Washington would pay almost the entire bill.
Another proposal would make a small change to the ACA that gives states more flexibility in covering low-income adults: allow states to cover adults up to 100% of the FPL through Medicaid, while shifting those between 100% and 138% of the FPL into subsidized marketplace plans. It’s a workable compromise, although policy experts warn that marketplace coverage could expose low-income patients to higher out-of-pocket costs.
This is why the argument that Medicaid expansion is fiscally irresponsible does not hold up. The evidence is overwhelming. States that expand Medicaid see lower uninsured rates and often measurable economic gains for hospitals and state budgets.
Even politically, the excuse collapses. Polling shows that 66% of residents in non-expansion states support expanding Medicaid.
Taken together, the picture is clear. The federal government would fund most of the expansion, and public support already exists. Yet many state officials continue to refuse.
So what do we do?
Obviously, Vanderbilt students can’t rewrite state law from a classroom. We can’t sign a governor’s pen or force a legislature to expand Medicaid tomorrow. However, we can refuse to let this injustice stay invisible. That is how policies like the coverage gap persist. Quietly. Hidden behind budget spreadsheets that reduce people to numbers.
Our responsibility as students and faculty is to bring this problem back into the public conversation. If Vanderbilt truly values academic excellence and integrity, silence cannot be our contribution to the problem. We can research it. Write about it. Argue about it in classrooms.
And most importantly, we can vote with this issue in mind.
The coverage gap is a line drawn by lawmakers who continually neglect care. And if policy can draw that line, policy can erase it.
