My friend Kevin avoided doctors for two solid years because he was uninsured and assumed he couldn't afford it. When he finally went to an ER for chest pain -- turned out to be a panic attack, thankfully -- the bill was $14,000. He qualified for Medicaid the entire time. Would have paid nothing. Nothing for the ER visit, nothing for follow-up care, nothing for the anxiety medication he clearly needed. He just didn't know. I still get mad about it. About 5 million Americans are eligible for Medicaid or CHIP right now and aren't enrolled.
In the 40 states plus DC that expanded Medicaid, any adult earning up to 138% of the federal poverty level qualifies. For 2025 that's $20,783 for a single person, $43,056 for a family of four. No asset test in most states. They don't care about your car or your savings account. Coverage is comprehensive -- primary care, specialists, hospital, prescriptions, mental health, substance abuse, lab work, preventive care. Most states charge zero premiums and copays between $0 and $4.
Ten states still haven't expanded. They're mostly in the South. If you're in one of them, Medicaid eligibility is much narrower -- generally limited to pregnant women, children, some parents, elderly, and disabled individuals, all at very low income levels. This creates the 'coverage gap': too much income for traditional Medicaid, too little for marketplace subsidies. It's bad policy and millions of people are stuck in it. If that's you, skip to the community health center section below.
For people above the Medicaid threshold, the ACA marketplace at HealthCare.gov has gotten genuinely more affordable. Premium subsidies expanded significantly in recent years. I've walked people earning $45,000 through enrollment and they've found silver-level plans for $50-80/month. Some people under $20,000 find $0/month plans. Open enrollment is November through January, but qualifying life events -- losing a job, moving, divorce, having a baby -- let you enroll any time. Don't wait for November if your circumstances changed.
Community health centers. I am evangelical about these. Over 1,400 federally qualified health centers, more than 15,000 locations, legally required to see patients regardless of ability to pay. Sliding scale fees based on income. I used one during a gap between jobs. Doctor visit plus blood work: $20. Same thing at a private practice would have been at least $350. They do primary care, dental, mental health, sometimes vision. Go to FindAHealthCenter.hrsa.gov and type in your zip code.
Prescription costs specifically: GoodRx app is free and routinely cuts prices 50-80%. Manufacturer patient assistance programs exist for most brand-name drugs -- the pharmaceutical companies themselves provide free or cheap medication if you're under certain income levels. Walmart, Costco, and others maintain lists of generics for $2-4 per prescription. For Medicare enrollees, the Extra Help program covers most prescription costs if income is under $22,590 and assets under $17,220. Apply at SSA.gov.
Kids' coverage is one area where the US does relatively well. Medicaid plus CHIP covers over 98% of American children. CHIP income limits go as high as 300% of poverty in some states -- about $93,000 for a family of four. Premiums are usually $0-50/month. Comprehensive: checkups, vaccines, dental, vision, ER, prescriptions, mental health. Enrollment is year-round, no open enrollment restriction. InsureKidsNow.gov or call 1-877-543-7669. If your kids don't have coverage, this should take priority over almost everything else on your financial to-do list.
