States' refusal to expand Medicaid leaves millions uninsured

While Tuesday marked the launch of statewide health insurance exchanges that promise to provide millions of Americans with affordable health care, throngs of poor and uninsured residents face a gap in insurance coverage that the sweeping legislation will do nothing to fix.

According to data analysis released by The New York Times Thursday, as many as 8 million people will remain outside of health care coverage envisioned under the terms of the Affordable Care Act (ACA), also known as Obamacare, because they live in states that have refused extensions to Medicaid, the national health insurance program for the poor.

Currently, 26 states — all with Republican governors or Republican-controlled legislatures — have thus far declined Medicaid expansion, leaving the health care situation of millions of uninsured people unchanged.

By contrast, in the 24 remaining states (plus Washington, D.C.) that are going ahead with Medicaid expansion, more than 8.7 million people are expected to be newly enrolled, according (PDF) to the Centers for Medicare and Medicaid Services.

The Times analysis said that while the 26 states that declined Medicaid expansion represent approximately half of the national population, they include a disproportionate 60 percent of the uninsured working poor and 68 percent of uninsured African-Americans and single mothers.

Under the terms of the ACA, Medicaid coverage was intended to be expanded to all adults with incomes up to 138 percent above the federal poverty line (which amounts to $15,856 for an individual), money that would be covered by the federal government at 100 percent of cost until 2016, and at 90 percent thereafter.

However, under a U.S. Supreme Court ruling on the ACA in June 2012, the federal government was barred from mandating states to enact Medicaid expansions. As a result, an insurance coverage gap currently exists where millions of people making less than $11,500 per year ($23,500 for a family of four) will have too much income to qualify for Medicaid but not enough to receive federal subsidies when purchasing insurance on a state-run health exchange.

"They are simply out of luck in those states," Stephen Zuckerman, a health economist with the Urban Institute, told Al Jazeera. "The law was written in a very structured way" in which the gulf between the poor and those who qualify for federal subsidies should have been covered by Medicaid expansion.

But as a result of the Supreme Court decision, a counterintuitive panorama has emerged where "their incomes are not high enough for them to get help," said Zuckerman.

HealthCare.gov, the new website set up by the federal government to explain the implementation of the ACA, acknowledges that there isn't too much a person can do in those states without expansions.

While encouraging people to check if they are covered by an existing state Medicaid policy, the website says the federal government can do little for those caught in a coverage gap absent new state policies. "States are continuing to make coverage decisions and they could expand Medicaid in the future," the website says.

While the New York Times analysis puts the number of the uninsured poor affected by a decision at 14 million, Zuckerman's Urban Institute says that number is closer to 11.5 million. The disparity in numbers is due to how one factors in the uninsured poor who don't have insurance but who could be eligible under existing state Medicaid policy — whether in states with an expansion or not.

The Times findings tracked numbers with expectations laid out by the Kaiser Family Foundation in a July brief, including the impact a lack of expansion would have on people of color.

"In states that do not expand Medicaid, poor, uninsured adults will not gain a new coverage option and likely remain uninsured," the report stated. "People of color make up the majority of uninsured individuals with incomes below the Medicaid expansion limit in states that are not moving forward with the expansion at this time."