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The Medicaid Gap Hits Home


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A few days before the recent deadline for Obamacare sign-ups, I visited with one of the exchange navigators in Colorado, a state that expanded its Medicaid program and is working hard to enroll uninsured residents. A 22-year-old woman named Justine came in seeking help. She brought in plenty of documentation for her $600 per month income. The navigator signed her up almost instantaneously.

Justine didn't ask any questions, and the navigator gave few details of what Medicaid was all about. Whether she understood what she was getting or how to use her new insurance card was an open question. Nevertheless, I was pretty impressed at the ease of gaining Medicaid coverage in Colorado.

Still, I couldn't help thinking of the millions of other Justines who live in states where they can't get access to Obamacare because they are too poor and yet are also not eligible for Medicaid. They live in states where politics triumphed over the Medicaid expansion that the Affordable Care Act included to boost insurance coverage for the poor.

About half of the states did not expand Medicaid to include people with incomes up to 138 percent of the federal poverty level (about $33,000 for a family of four). Some five million people in those states are caught in the gap between Medicaid and Obamacare. They earn too much to qualify for their state's existing Medicaid program but too little to qualify for subsidies under Obamacare.

They're out of luck because Obamacare did not consider that, even with federal dollars to support it, some states might reject Medicaid expansion. Nor did supporters of the law consider that the Supreme Court would allow states to opt out of the expansion. While those not eligible for Medicaid can shop in the exchanges, if their income is less than 138% of poverty level, they aren't eligible for subsidies, and without a subsidy most can't afford insurance. Many also live in states where Medicaid doesn't offer benefits for childless adults.

Georgia is one state that chose not to expand Medicaid. About 140,000 Georgians have enrolled in the state's Obamacare exchange while 400,000 are trapped in the Medicaid-Obamacare gap. Governors in states not expanding say that they can't trust the federal government to honor its commitment to fund its share of the expansion. Georgia Gov. Nathan Deal told the Atlanta Journal-Constitution he was "not interested in growing entitlements especially through an already broken and unsustainable Medicaid program dictated to the states by Washington."

Deal and others have seemingly been willing to leave federal funds on the table. That was puzzling so I rang up Ian Haney Lopez, a law professor at the University of California, Berkeley, who has just published a book called Dog Whistle Politics, to explore the reasons more deeply. Unconscious racism is at work here, he said. "Racial bias is integral to the politics of Medicaid. Opponents are strongly using a racial narrative to impugn the poor and the government."

I asked Haney Lopez why the arguments about the federal government paying for most of the expansion did not seem persuasive to some states. He explained that opponents don't care about the poor being left out, "their number one intention is proving government doesn't work."

Whatever racism, hidden or otherwise, is involved, it brings me back to worrying about how these five million Americans caught in the Medicaid-Obamacare gap will pay for their care. Most likely they will find their way to emergency rooms and community clinics as they always have done. In the ERs they'll get episodic care for the ailment at the moment but no preventive or chronic care. They'll try to go to community clinics for that.

Now there's a difference, though. Will they have to stand in the queue behind the millions of other Americans who use community health centers but now have Obamacare? Thanks to the Obamacare tax subsidies, some formerly uninsured patients are now paying customers. These clinics need revenue and are also likely to be short-handed because of all the newly insured people turning up for long-needed care. Inequality in health care remains.

More Blog Posts by Trudy Lieberman

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Trudy Lieberman, a journalist for more than 40 years, is an adjunct associate professor of public health at Hunter College in New York City. She had a long career at Consumer Reports specializing in insurance, health care, health care financing and long-term care. She is a longtime contributor to the Columbia Journalism Review and blogs for its website,, about media coverage of health care, Social Security and retirement. As a William Ziff Fellow at the Center for Advancing Health, she contributes regularly to the Prepared Patient Blog. Follow her on twitter @Trudy_Lieberman.

Tags for this article:
Medicare/Medicaid   Health Care Access   Trudy Lieberman   Health Care Cost   Pay for your Health Care   Minority Health and Health Disparities   Health Disparities   Inside Healthcare   Health Insurance  

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