WASHINGTON — One
month after undergoing a partial hysterectomy in 2011 to remove a rare
form of ovarian cancer, Erika Neal of St. Louis got a double dose of
more bad news: Her salary as deputy director of a nonprofit museum was
being cut and her job-based health coverage was being eliminated.
Without insurance, she went more than a
year without tests that would tell her whether the cancer had
reappeared. Neal continued to work, however, and now relies on an
emergency state program to pay for the quarterly tests.
But
when the program ends in December, she won’t be able to afford the
diagnostic tests because her salary has been cut by 75 percent since
2009. As an adult with no children, she’s also ineligible for Medicaid,
the state-federal health plan for the poor and disabled.
With no options for coverage, Neal rightly fears for her life next year.
“I’m
always praying, but in 2014, my prayers will be ever more fervent,” she
said. “If the cancer comes back and it’s not detected, it’ll kill me.
Most ovarian cancers, by the time you find out you have it, you just
need to plan your funeral. So it’s a blessing they have a test for it,
but I can’t get the tests if I don’t have health insurance.”
Neal
could rest easier if she lived in one of the 23 states where Medicaid
eligibility is being expanded for low-income parents and childless
adults next year under the Affordable Care Act. Michigan appears close
to expanding Medicaid eligibility.
But
Missouri and 20 other Republican-led states aren’t participating in
Obamacare’s Medicaid expansion, fearing the cost would require state
budget cuts in other areas. The remaining states are still debating the
expansion.
That leaves Neal and 5.5 million others
in those 21 states to fend for themselves in the “coverage gap,” a
bureaucratic twilight zone where people with poverty-level incomes don’t
qualify for Medicaid and can’t get tax credits to help buy coverage on
the new insurance marketplaces. Enrollment for them begins in October
and they open in January.
With limited access to preventative care,
many in the coverage gap with manageable chronic illnesses could end up
seeking primary care services in hospital emergency rooms, where
medical aid is costly and fleeting.
“If
they fail to get an insurance card and don’t have ongoing adequate
coverage, that’s how they’re going to continue to get care, in the most
expensive, least efficient, least helpful way that they can,” said Ellen
Kugler, executive director of the National Association of Urban
Hospitals.
Gerald
Friedman, a health care economist at the University of Massachusetts
Amherst, summarized the options for those caught in the coverage gap.
“There’s no way they can afford individual coverage at that income
level, so they’ll do what they do now, which is they go to the free care
pools in the hospitals, they go to public health clinics, they borrow
from friends, they go to free clinics,” Friedman said, “and they just
get sicker and sicker.”
While
the legislative, judicial and executive branches all had a hand in
creating the coverage gap, it was not by design. It was an unintended
consequence of the 2012 Supreme Court decision that upheld the
Affordable Care Act.
The law was supposed to provide health
insurance for most Americans next year by expanding Medicaid in all
states to people earning up to 138 percent of the federal poverty level.
That’s about $15,900 for an individual in 2013, or nearly $32,500 for a
family of four.
Tax credits would then go to other low-
and middle-income people to help them buy coverage on the insurance
marketplaces. If the Medicaid expansion was implemented in every state
as originally planned, an estimated 22.3 million Americans likely would
have gained coverage next year, according to the Urban Institute, a
nonpartisan social and economic policy think tank.
But when the Supreme Court ruled that
states could opt out of the expansion, Republican-led states took
advantage. Rather than expand their Medicaid programs, most kept their
programs as is – open mainly to the poorest of the poor.
In 33
states, parents must now earn less than the federal poverty level –
$19,530 for a family of three – to be eligible for Medicaid, according
to the Kaiser Family Foundation, a nonpartisan health care research
group. Eighteen of these states limit eligibility to parents in severe
poverty, which is 50 percent of the federal poverty level or lower.
Georgia
is one such state. An estimated 534,000 Georgia residents will fall
into the coverage gap, according to the Urban Institute.
They include people like Ellen Wall, an unemployed nanny in the Atlanta area.
After
developing a lung infection following a bout with the flu last year,
Wall spent three days in the hospital recovering. Her $6,000 bill was
more than she could hope to pay on her $13,000 annual income. With no
children, Wall couldn’t get Medicaid in Georgia, so the hospital ended
up footing most of her bill.
While
she counts her blessings, the experience taught her that without a
source of steady coverage, she’s one illness away from financial ruin.
At a recent meeting of the Atlanta chapter of the National Domestic
Workers Alliance, Wall was moved to tears as she discussed her
situation.
“I
got very sad talking about it because I realized that as a nanny, I work
very, very hard,” she said of her time spent caring for children, who
attend costly private school. “I’m loving and caring and trustworthy. I
get the kids ready to go to school, but if the money gets tight, then
all of a sudden, it’s the school or me and the school will win out and
I’m stuck in between, without a job or health care.”
Like
most states that have rejected the Medicaid expansion, Georgia officials
have cited the cost as the biggest deterrent. But under the Affordable
Care Act, the federal government has pledged to pay all medical costs
for newly eligible Medicaid enrollees in 2014, 2015 and 2016 and no less
than 90 percent of their costs thereafter.
Earlier this month, Health and Human
Services Secretary Kathleen Sebelius was in Atlanta to promote Obamacare
and to urge Georgia Gov. Nathan Deal to adopt the Medicaid expansion.
Deal said he didn’t appreciate her efforts to sway public opinion.
“Instead of adjusting and accepting the
Supreme Court opinion, it appears that the tactic is to try to
intimidate states, which is exactly what the Supreme Court said that the
federal act would not allow them to do,” Deal told reporters.
Some
Republican lawmakers worry that President Barack Obama’s plan to pay for
the new Medicaid enrollees could change or go by the wayside, like
other provisions of the health care law that have been waived or
postponed by the Obama administration.
Neal, of Missouri, isn’t buying that argument.
“In
28 years, the federal government has never missed a Medicaid payment to
the state of Missouri, so the notion that the government won’t pay its
share? The historical record does not bear that out,” Neal said.
In Georgia, state officials have said there aren’t enough caregivers to handle an expanded Medicaid population.
But
that’s a false argument, said Cindy Zeldin, executive director of
Georgians for a Healthy Future, a nonprofit group that advocates for
access to affordable health care. She said that concerns about the cost
and provider shortages would be mitigated by the boost in jobs and
spending that the Medicaid expansion would create for the state economy.
“We
are not bringing in new people from another state into Georgia,” Zeldin
said. “We’re talking about Georgians who are already here, who already
have health care needs, who are already sporadically using the safety
net or hospitals seeking care only when it’s too late.”
