How Many 2 Go Into 1
Macedonio Heninger
The report also finds that many of the new poor will be in countries that already have high poverty rates. A number of middle-income countries will see significant numbers of people slip below the extreme poverty line. About 82% of the total will be in middle-income countries, the report estimates.
The convergence of the COVID-19 pandemic with the pressures of conflict and climate change will put the goal of ending poverty by 2030 beyond reach without swift, significant and substantial policy action, the World Bank said. By 2030, the global poverty rate could be about 7%.
Progress was slowing even before the COVID-19 crisis. New global poverty data for 2017 show that 52 million people rose out of poverty between 2015 and 2017. Yet despite this progress, the rate of reduction slowed to less than half a percentage point per year between 2015 and 2017. Global poverty had dropped at the rate of around 1 percentage point per year between 1990 and 2015.
In addition to the $1.90-per-day international poverty line, the World Bank measures poverty lines of $3.20 and $5.50, reflecting national poverty lines in lower-middle-income and upper-middle-income countries. The report further measures poverty across a multidimensional spectrum that includes access to education and basic infrastructure.
The prospect of less inclusive growth is a clear reversal from previous trends. Shared prosperity increased in 74 of 91 economies for which data was available in the period 2012-2017, meaning that growth was inclusive and the incomes of the poorest 40 percent of the population grew. In 53 of those countries, growth benefited the poorest more than the entire population. Average global shared prosperity (growth in the incomes of the bottom 40 percent) was 2.3 percent for 2012-2017. This suggests that without policy actions, the COVID-19 crisis may trigger cycles of higher income inequality, lower social mobility among the vulnerable, and lower resilience to future shocks.
The World Bank Group, one of the largest sources of funding and knowledge for developing countries, is taking broad, fast action to help developing countries strengthen their pandemic response. We are supporting public health interventions, working to ensure the flow of critical supplies and equipment, and helping the private sector continue to operate and sustain jobs. We will be deploying up to $160 billion in financial support over 15 months to help more than 100 countries protect the poor and vulnerable, support businesses, and bolster economic recovery. This includes $50 billion of new IDA resources through grants and highly concessional loans.
Two states (South Dakota and North Carolina) implemented Medicaid expansion in 2023, reducing the number of low-income uninsured people nationally without access to Medicaid. Expansion in those two states brings the count to 40 states and the District of Columbia that have adopted expansion, leaving ten states that have not adopted it. Using data from 2022, the most recent year available, this brief presents estimates of the number and characteristics of uninsured people in the ten non-expansion states who could be reached by Medicaid if their states adopted the Medicaid expansion. An overview of the methodology underlying the analysis can be found in the Data and Methods, and more detail is available in the Technical Appendices.
The coverage gap exists in states that have not adopted the ACA Medicaid expansion for adults who are not eligible for Medicaid coverage or subsidies in the Marketplace. The ACA expanded Medicaid to nonelderly adults with income up to 138% FPL ($20,782 annually for an individual in 2024) with enhanced federal matching funds (now at 90%). The Medicaid expansion established a uniform eligibility threshold across states for low-income parents and newly established Medicaid coverage for adults without dependent children. However, the expansion is effectively optional for states because of a 2012 Supreme Court ruling. As of February 2024, 40 states and DC have expanded Medicaid (Figure 1).
States that have not implemented the expansion have uninsured rates that are nearly double the rate of expansion states (14.1% compared to 7.5%). People without insurance coverage have worse access to care than people who are insured. One in five uninsured adults in 2022 went without needed medical care due to cost and uninsured people are less likely than those with insurance to receive preventive care and services for major health conditions and chronic diseases.
Nearly three-quarters of adults in the coverage gap are concentrated in three states in the South. Four in ten people in the coverage gap reside in Texas, which has very limited Medicaid eligibility, and consequently, a large uninsured population (Figure 4). An additional 19% of people in the coverage gap live in Florida and 12% live in Georgia. In total, 97% of those in the coverage gap live in the South. Seven of the 16 states in the South have not adopted the Medicaid expansion, and the region has more low-income, uninsured adults and higher uninsured rates compared to other regions.
People in the coverage gap are disproportionately people of color. Nationally, over six in ten (62%) people in the coverage gap are people of color, a share that is higher than for non-elderly adults generally in non-expansion states (53%) and for non-elderly adults nationwide (46%) (Figure 5). These differences in part explain persisting disparities in health insurance coverage by race/ethnicity.
Despite having low income, nearly six in ten people in the coverage gap are in a family with a worker, and over four in ten are working themselves (Figure 6). Adults who work may still have incomes below poverty because they work low-wage jobs. People with incomes below poverty often do not have access to employer based health insurance or if available, it is often unaffordable. The most common jobs among adults in the coverage gap are cashier, cook, waiter/waitress, construction laborer, maid/housecleaner, retail salesperson, and janitor. For parents in non-expansion states, even part-time work may make them ineligible for Medicaid.
Some people in the coverage gap have significant current health care needs. KFF analysis of the 2022 American Community Survey shows that more than one in six (17%) people in the coverage gap have a functional disability, meaning they have serious difficulty with hearing, vision, cognitive functioning, mobility, self-care, or independent living. Even with functional disabilities, many are not able to qualify for Medicaid through a disability pathway leaving them uninsured. Older adults, age 55-64, an age of increasing health needs, make up 18% of people in the coverage gap. Research has demonstrated that uninsured people in this age range may leave health needs untreated until they become eligible for Medicare at age 65.
If all states adopted the Medicaid expansion, approximately 2.9 million uninsured adults would become newly eligible for Medicaid. This number includes the 1.5 million adults in the coverage gap and an additional 1.4 million uninsured adults with incomes between 100% and 138% FPL, most of whom are currently eligible for Marketplace coverage but not enrolled (Figure 7 and Table 1). Most of the adults who are currently eligible for coverage in the Marketplace qualify for plans with zero premiums; however, even with no premiums, Medicaid could provide more comprehensive benefits and lower cost-sharing compared to Marketplace coverage. The potential number of people who could be reached by Medicaid expansion varies by state.
A substantial body of research continues to point to largely positive effects from the Medicaid expansion. KFF reports published in 2020 and 2021 reviewed more than 600 studies and concluded that expansion is linked to gains in coverage, improvement in access and health, and economic benefits for states and providers. More recent studies generally find positive effects related to more specific outcomes such as improved access to care, treatment and outcomes for cancer, chronic conditions, sexual and reproductive health and behavioral health. Studies also point to evidence of reduced racial disparities in coverage and access, reduced mortality and improvements in economic impacts for providers (particularly rural hospitals) and economic stability for individuals.
Renewed debates over Medicaid expansion could lead to additional states adopting the expansion. Legislative opposition to expansion may be softening in some states, driven by financial challenges facing rural hospitals as well as interest in taking advantage of the additional federal funding. If additional states were to expand Medicaid, it could help limit increases in the number of people who become uninsured because of the unwinding of the Medicaid continuous enrollment provision. In South Dakota and North Carolina, Medicaid enrollment dropped initially after the start of the unwinding, but began increasing again following implementation of Medicaid expansion in each state.
\nCurrently, 800 million people spend at least 10 percent of their household budgets on health expenses for themselves, a sick child or other family member. For almost 100 million people these expenses are high enough to push them into extreme poverty, forcing them to survive on just $1.90 or less a day. The findings, released today in Tracking Universal Health Coverage: 2017 Global Monitoring Report, have been simultaneously published in Lancet Global Health.
\n\"It is completely unacceptable that half the world still lacks coverage for the most essential health services,\" said Dr Tedros Adhanom Ghebreyesus, Director-General of WHO. \"And it is unnecessary. A solution exists: universal health coverage (UHC) allows everyone to obtain the health services they need, when and where they need them, without facing financial hardship.\"
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