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Feature Medicaid

Challenges facing Medicaid expansion in the US

BMJ 2013; 346 doi: (Published 29 May 2013) Cite this as: BMJ 2013;346:f3261
  1. Douglas Noble, Commonwealth Fund Harkness fellow (UK)1,
  2. Nikola Biller-Andorno, Commonwealth Fund Harkness fellow (Switzerland)2,
  3. Jason M Sutherland, Commonwealth Fund Harkness fellow (Canada)3,
  4. Matthew Anstey, Commonwealth Fund Harkness fellow (Australia)4
  1. 1Weill Cornell Medical College, New York City, NY
  2. 2New England Journal of Medicine/Harvard University, Boston, MA
  3. 3Jason M Sutherland, Centre for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada
  4. 4Institute for Health Policy, Kaiser Permanente, Oakland, CA
  1. djn2004{at}

Douglas Noble, Nikola Biller-Andorno, Jason M Sutherland, and Matthew Anstey give an international perspective on some of the key battlegrounds that could make or break the expansion of Medicaid

The Patient Protection and Affordable Care Act (ACA) 2010 received two major boosts last year with the upholding of most of the law as legal by the Supreme Court, and the re-election of President Barack Obama. As 2013 proceeds, critical parts of the law are being implemented across the United States.

At the heart of the ACA is the federal objective of expanding insurance coverage. A substantial proportion of expanded health insurance is anticipated to be achieved by optional state level expansion of Medicaid (the government plan for poor and disabled people). Currently, there are restrictions on eligibility that vary from state to state. Extending Medicaid to those whose income is below 138% of the federal poverty level is projected to increase eligibility for under 65 year olds by about 12 million.1

International comparisons

This potentially massive expansion across 50 diverse states is reminiscent of major changes in health systems in Europe, Canada and the Antipodes, since the end of the second world war: the National Health Service in Britain introduced a single payer single provider system for all citizens in 1948;2 in Switzerland mandatory health insurance for the entire population was introduced with the Federal Law on Health Insurance in 1994;3 the Australian government introduced a national health insurance scheme in …

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