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Health Care Trapdoor: No Medicaid, No Tax Rebates (FAQ)

Data from the Urban Institute and federal Centers for Medicare & Medicaid Services, used above, show states that have Medicaid expansion (purple and includes Hawaii) and ones that do not (yellow and includes Alaska). Click on each state for more information.  

Most days, Robin Evans starts her newspaper route in Grangeville, Idaho at 3:30 a.m. Sundays are the only exception — then she gets to sleep in an extra half hour. Evans, 53, also works in the cafeteria of an elementary school, but neither part-time job offers health insurance.

As originally passed by Congress, the Affordable Care Act (ACA) — the major health care reform law designed to expand coverage for tens of millions of people and address soaring costs — would have created an affordable insurance option for Evans. Together with her husband, she makes less than $14,000 a year.

Sarah Paul, a pre-med student in Nebraska, recently turned 19 and finds herself without health insurance, or a reasonable way to get it, for the first time in her life. Photo courtesy of Sarah Paul

But after the Supreme Court ruled in 2012 that states could block new eligibility rules for Medicaid, lawmakers in Idaho and 25 other states turned down federal funding to expand the government insurance program for those in need, citing cost concerns and philosophical opposition to the key ACA provision.

Now, 7 million citizens fall into the resulting coverage gap, according to an Urban Institute study released last year and updated reports. This diverse group has one thing in common: Like Evans, they all earn too much to qualify for existing Medicaid coverage, but don’t earn enough to qualify for subsidized premiums in the recently-launched health insurance marketplaces.

“These are folks who have very few options,” said Lisa Dubay, a co-author of the Urban Institute study.

Without federal premium subsidies, which kick in only for households above the poverty line, the cheapest option on Idaho’s insurance marketplace would cost Evans nearly a third of her income, according to a subsidy calculator from The Henry J. Kaiser Family Foundation.

Originally, congressional lawmakers intended to let all citizens below the poverty line enroll in Medicaid. “The Supreme Court decision dealt a real blow to poor people in the United States,” said Dubay, who said she was surprised by the number of states that turned down significant federal funding for the program.

Evans has gone uninsured since 2008 and knows the risks all too well. Last year, an emergency kidney stone intervention left the grandmother of four with over $22,000 in medical debt.

Insurance Coverage Gap
Insurance Coverage Gap: Click for Larger Version

“If I get sick again, it’s just going to be another medical expense that I can’t pay,” she said, but she dismisses the idea of filing for bankruptcy. “If I had $750 for the lawyers fee and court costs, I’d just want to pay that toward the debt.”

In Nebraska, state lawmakers have put University of Nebraska Omaha sophomore Sarah Paul in a grimly ironic position. After her father’s death left the family without private insurance, Paul got coverage under the Children’s Health Insurance Program (CHIP), the Medicaid expansion program for those 18 and under.

Paul said the health care she received under the program felt comparable to private insurance, though there were fewer providers from which to choose.

But on Oct. 1, 2013, when others began shopping for subsidized coverage online in the new health insurance marketplaces, Paul woke up for the first time without coverage or any way to get it. Recently turned 19, she had aged out of CHIP coverage.

Paul, a full-time pre-med student, doesn’t earn nearly enough from a part-time daycare job to qualify for subsidized coverage in the marketplace — and Nebraska, like most other opt-out states, excludes all childless adults without disabilities from Medicaid, regardless of income.

“I’m not going to quit school now to get a job with benefits,” said Paul, who hopes to work as an emergency room doctor someday. For now, she recognizes that a trip to the emergency room could leave her in deep medical debt.

“I understand what they’re saying,” Paul said of Medicaid opponents in Nebraska.  “It just kind of sucks, because it’s not my fault that I don’t have health insurance.”



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