August 30, 2013 at 11:39 pm

Medicaid 'gap' worries many

5.5M in 21 states at risk of losing access to care amid expansion fight

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.”

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 the health care law’s Medicaid 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.

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.

When the Supreme Court ruled that states could opt out of the expansion, most Republican-led states kept their Medicaid programs 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.