Who gets left out of Obamacare?

The main purpose of health reform, said the president at a recent press conference, was to provide health insurance to people at affordable rates. He meant the nub of Obamacare — the state shopping exchanges with their smorgasbord of insurance policies — would give coverage to millions of Americans who did not have insurance.

Whether that coverage will be affordable or comprehensive for families remains to be seen. What is crystal clear, however, is that there will be one group of Americans who won’t even make it to the insurance gateway. They live in the 27 states that have so far chosen not to expand their Medicaid programs to cover more of the uninsured. Many of those left out are childless adults — a group rarely covered by Medicaid even if they are among the poorest of the poor.

About 51 million people were uninsured at the time the president signed the Affordable Care Act (ACA). Congress expected that even after ACA went into effect, some 20 million would remain uninsured. Around 15 million would be eligible for Medicaid after state expansion and another 15 million could get subsidies to shop in the exchanges. Then, last year the Supreme Court messed up that scenario by ruling that states were not required to expand their Medicaid programs, and half of them, mostly in the west and south said “no” even though the federal government was footing most of the bill. According to a report from the Kaiser Commission on Medicaid and the Uninsured released a few weeks ago, many of those who won’t have a chance for coverage live in Florida, Texas and Georgia.

Here’s what happens to residents in states that have opted not to expand Medicaid coverage: People with incomes between 100 and 138 percent of the federal poverty level ($15,900 for a single person and $32,500 for a family this year) can get a tax subsidy to help them buy insurance on the exchanges. But because of the way Congress crafted the law, people with incomes below the poverty level are barred from receiving subsidies in the exchanges because they were supposed to be eligible for expanded Medicaid.

In a perversity of Obamacare, this means that some of those with the lowest incomes will get no government help buying insurance. Someone who has an income that’s 99 percent of the poverty level cannot get financial assistance to purchase health insurance from an exchange, but someone whose income is 101 percent above can.

This is the opposite of what happens in means-tested programs like food stamps or supplemental security income (SSI) where people with incomes over the eligibility limit don’t qualify. When it comes to health insurance subsidies, people with incomes below the line don’t qualify.

What are their options? Basically none. Without subsidies, people in this predicament can hardly afford insurance. It’s tough even for families with much higher incomes to pay for it. That’s why Congress authorized the subsidies in the first place. These people will continue to be uninsured and can only hope that Congress changes the law or that their states have a change of heart next year when their legislatures reconvene.

Health insurance reform was never about equity, the kind that exists in the national health insurance systems of other countries where everyone is covered and entitled to the same benefits. Under Obamacare, some insurance coverage will be worse than others and will still leave families on the hook for medical bills and vulnerable when catastrophic illness strikes.

Denying Medicaid coverage and/or subsidies to the poorest of the poor makes these inequities all the more apparent. All too many states and Obama have some more explaining to do.

Trudy Lieberman is a journalist and an adjunct associate professor of public health, Hunter College. She blogs regularly on the Prepared Patient blog.

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  • Mengles

    “In a perversity of Obamacare” – very well said about the entire bill.

  • BudgetDoc.com

    Great post and good insights, Trudy.

    This seems like a pretty big oversight. Is there anything that these people can do, short of lobbying their legislature to close the cracks they’ve fallen into, to improve their position?

  • Anthony D

    If you can use Google and do some basic research you will find out for yourself just how bad it is and come January 01 just how much worse it is going to get.

    But to get you started, a 2700 page bill backed by 13,000 pages – and climbing – cannot be good. Add in the IRS who is going to be handling the enforcement of Obamacare, what could possibly go wrong!

  • Ron Smith

    Obamacare was never about providing healthcare coverage. It was always only about political control. If it was an attempt to provide health insurance coverage so that providers and hospitals could get paid, then it would have been far cheaper simply to increase the reimbursements for those people under Medicaid as it existed prior to Obamacare.

    Why would the government pay $20 for a hammer when they can pay $450?

    Let me give you a on-going case in point just so you don’t think I’m ranting politically. The Medicaid CMOs in Georgia has been signing up newborns left and right. Especially they have been targeting those families who **already have insurance**! People with newborns and regular insurance attempt to come to our office and use their Medicaid coverage (which is **secondary**) all the time! Why pay the copay of their regular insurance when its all covered by Medicaid?

    Why is the government doing this? Its absolutely not because these people need insurance.

    Its because Obamacare is about government control. Sorry, but I don’t that.

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

    • ErnieG

      I agree. When Obamacare was being debated, I can’t recall Mr. Obama arguing for anything but “we need to do something,” with few specifics other than the obvious bones about extending insurance coverage, and almost everything else pointing towards increased government intrusions. He failed to understand the fundamental problem- Americans were not getting medical care NOT because they had no insurance, but rather because it is too expensive, and there is nothing about the market place that reduced that economic pressure, and all the players in medical care are becoming large entities unto themselves, with interests that are aligned against a patient-physician relationship with strong generalists. Obamacare will create dumbed down statistically driven large population medical care, “covering” everyone, and it will still be expensive. I keep thinking about Obama, and I think “what a tool”.

    • macbook

      Hi Dr. Smith,

      Can you explain your post above in more depth? Not entirely should I understood exactly what you were saying..

      • Ron Smith

        Sure. Parents of patients who are even already coming to see us, come home with a subsequent newborn. They already have insurance for their families and thus these newly born babies. Yet the Medicaid CMOs are signing them up for Medicaid. So Medicaid is their secondary insurer after that primary insurance.

        They then proceed to come to the office, try to present the Medicaid card as their primary so they won’t have to pay the copay required by their private insurer.

        This is fraudulent, but the CMOs are apparently doing this at the direction of, and with full knowledge from, the federal/state Medicaid programs.

        There is clearly no economic reason for these families to have Medicaid when they already have private insurance. The only reason to have Medicaid therefore is for the federal government to push out private insurance and control people the way they control them with entitlements. This is nothing more than continued slavery through economic dependence.

        We do not tolerate this at our office ever. I will never work for the government and will quit practice before I give over the fruits of my labor to them. Ultimately, what the fed want is to control me, the physician, like they want to control and regulate everything else.

        Warmest regards,

        Ron Smith, MD
        www (adot) ronsmithmd (adot) com

        • macbook

          Thanks for the clarification.

          That doesn’t sound ethical at all. If they already have insurance, they shouldn’t be allowed to sign up for medicaid and then use medicaid as primary when its not.

          How do you see medicine changing for physicians practices as obamacare gets implemented?

          • Ron Smith

            It isn’t ethical. But it is calculated. We’ve been seeing this for about the last two to three years.

            For us, we had to make the choice whether we were going to be a government ‘whipping boy’ or not. The decision came easy for me though when Peachstate and Wellcare (who were are are still signing up newborns the way I described left and right and for $$$) had backlogs of payments for services which they were denying or requiring claim submits reached some 6 months or longer.

            I can’t pay my staff if the insurers are unethical in the way they do business with me. I told my practice manager that to drop them. She shuddered at first wondering how we were going to survive financially without them.

            Our medicaid patient percentage dropped from just under 45% to now somewhere close to 12%. Our practice is thriving. I and each of the providers have scheduled slots for about 25 visits a day. I go home usually by 5:30 and when I’m done, I can look back over the day and say I did a good job and took care of my patients.

            Our income has risen. My practice manager saw the positive effects of getting off the government ‘gravy train’ almost immediately.

            We make careful considerations of children with special needs and those who have rarer conditions and need the time that we can provide.

            We have almost zero staff turnover. We all love coming to work. Our patients treat us well. We communicate with them effectively.

            But I digress…what is happening on the other side of this coin is very bad. The practitioners who have swallowed the ‘meaningful use’ hook and are struggling to make ends meet by having everyone seeing 40+ patients a day are swimming with their nose just above the water. Their waiting rooms look like the ER and the reports we get from patients is that the facilities are often dirty and disgusting.

            I feel for my fellow physicians terribly, but there is nothing I can do. Seeing more patients per day will not result in the practices they want nor will it improve the healthcare in this country. Adding NPs outside of a strong physician/np team will only extend the government abuse of them as providers. This is sad to me because I highly respect those NPs that work for me. They will be terribly abused too.

            Ron Smith, MD
            www (adot) ronsmithmd (adot) com

  • Michelle

    The states that are denying expansion of Medicaid are doing no wrong, they’re just trying to stop the bleeding. Look to the man who put his name to the bill – Obama – for the fundamental perversity that pervades the ACA.

  • Guestly

    Supreme Court messed up on the Commerce Clause? It occurs to me the mess occurred in the mandate?

    • Mandy Miller

      Our President, widely lauded as a former “Professor of Constitutional Law”, should have known better than to sign into law his signature healthcare bill which was actually in violation of the US Constitution.

      Obamacare’s violation of the Commerce Clause was unconstitutional. The US Supreme Court upheld the US Constitution.

      Thank God for the Separation of Powers.

  • guest

    i have a hunch this will get addressed. i am thinking that when the billwas constructed this population was not an issue. Given the law is everyone is mandated to have insurance this will get sorted out.

    • meyati

      But how long will it take-10 years? a hundred years?

      • guest

        I thought i was the ultimate pessimist so for me to feel hopeful that it would be fixed was a big deal. But you may be right now since we do live in the USA.

  • Steven Shie 谢涤非

    It seems impossible to achieve universal coverage without a single payer system. In Obama-care’s defense, ACA is not the reason ” some insurance coverage will be worse than others.” There is a strong consensus of delegitimization government in health care decision making in the U.S. but the current multipayer system can never fill the gap.

    • Dorothygreen

      It doesn’t have to be a single payer like Canada. It can be insurance. No Medicaid. Insurance premiums subsidized directly to the individual up front according to income. Medicare A should continue to be collected and provided as it is now. Medicare part B could be obtained through the exchange.

      All providers/insurers in the medical industrial complex need to negotiate prices/premiums for basic services with the government. Insurance companies can also sell supplemental insurance for such things as choice of physicians, private rooms, extra perks at a profit. This maintains the competition and supports their investments. They do all the administrative work. Government makes sure no one is cheating the other or the government.

      Switzerland thought this through in 1995 and it is working as well or better than any other health care system. Exchanges are the only way to purchase this mandated insurance. Subsidies are provided to the individual by the government to buy insurance, not a convoluted method linked to income taxes or by special clinics and hospitals for the poor. Employers have the option to contribute, not a mandate. It is affordable and fair.

      ACA may offer coverage for more but indeed as the article points out many folks are going to fall through the cracks and many will not be able to afford insurance as long as basic service prices and premiums are in the hands of the providers and insurance companies. Whether it is a single payer or the Swiss Insurance having the government negotiate up front is key to affordable and fair health care for all.

      There is a major difference between the US and Switzerland that will still make health care in the US more costly, maintain high premiums and needlessly use income tax dollars even if we finally get the basics of health care as a single payer or Swiss system model. That is our SAD diet reflected in an obesity rate of 34% and the ever increasing amount of chronic preventable non-communicable diseases which eats up over half of the US health care dollars.
      No other country would tolerate this. Already, some countries are addressing this through some kind of excise tax on sugar (and refined grains), unnatural fats and sodium in processed foods. Hungary seems to have done it well; Denmark not so well.

      Bottom line. We must reform our health care reform and our eating culture. Switzerland is the best model for a US health care system and the US anti-tobacco model is the best model to promote a healthy diet and reduce the American addiction to sugar, refined grains, vegetable oils and grain fed animals.

    • GT

      “There is a strong consensus of delegitimization government in health care decision making in the U.S.”

      “Health care decision making” was never a designated function of the US Federal Government in the first place – there can be no “delegitimization” of something that never was a legitimate role of the State anyway.

      That’s like moaning that “There is a strong consensus of delegitimization government in soft drink size decision making in the U.S.”

      No, our Founding Fathers did not set up the kind of State where faceless rulers would make your health care decisions, or tell you what size soft drink you’re allowed to buy. Thank goodness that some citizens still understand and recognize that.

  • Michael Smothers

    I’m sure there are ongoing studies as to who will be left out of health insurance despite Obamacare. Both sides will release data. The working poor who don’t qualify for Medicaid because they make too much to qualify, especially in those states that don’t raise eligibility, or other reasons, like criminal issues. Felonies, or drug abuse excludes some from Medicaid. Also those on Medicare can’t get gap coverage if they are under 65. and aren’t eligible for the exchanges. There are many more that will still be uncovered. That will need to be fixed over time, or we’ll have to go to single payor insurance.

    • GT

      “…or we’ll have to go to single payor insurance.”

      I’m pretty sure that was Obama’s plan all along.

      If he had just wanted to fix up some of the flaws in our traditional system, the ones that affected maybe 10% of the population, he could have done that, and nothing would have changed for the nearly 90% of Americans who were perfectly fine with the health care they were getting.

      Instead, he went and wrecked the system for everyone, so that to many people “single payer” will look like the only viable choice.

      It’s like someone smashing your kneecap and then holding out the offer of a “free” crutch to get you to vote for them. One they’ve smashed your kneecap, a crutch starts to look like a pretty neat “gift”.


    Google “PNHP” (Physicians for a National Health Program) and learn what a real health care reform can be like for everyone instead of this patchwork system in place now.

  • petromccrum

    I will give you another example of the effect of Obamacare. My insurance company has already informed me that my policy will NOT be renewed. I must go the the exchange to purchase another policy. the rate is a 50% increase over my current policy. Where do I get that income from? 50% is a huge amount for anyone. As I have said from the very beginning this entire program was/is a HUGE MISTAKE. This benefits no one!!

    • guest

      so sorry to hear that! Are they terminating the plan or other reasons. what a mess!

      • Guest

        I don’t know about the above commenter, but my policy will not be renewed because it doesn’t meet all the “bells and whistles” that Obamacare requires (free birth control, free addiction & mental health, etc). I liked my old policy. Now I, too, have to go out and find one on the exchanges.

  • querywoman

    Requiring people to buy it out of their monthly disposable income then rewarding them with tax subsidies won’t work.
    Here’s what will happen in Texas: the public hospitals will demand that the lower income buy one of those insurance plans before dipping into local funds. The public hospitals will still supposed to be providing care. There were will be fights, and some people will be denied services.

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