Caught in the Gap

What Hostility to Health-Care Reform Has Wrought

In 2012, the Supreme Court upheld the Affordable Care Act’s requirement that most Americans obtain health insurance or pay a penalty. In so doing, the Court preserved the law’s backbone. As we are now discovering, however, the same Supreme Court decision also cut out the ACA’s heart: the justices struck down the law’s requirement that the states expand their Medicaid programs to cover all adults at or below 138 percent of the poverty level. The requirement is now an option. Each state can choose whether to expand its Medicaid program or keep it as it is. As of March 2014, twenty-four states have refused to expand their programs—despite the fact that the federal government promised to pick up more than 90 percent of the costs for the next decade. Most of these are “Red States” in the Southeast and Mountain regions, along with the vertical line of states from South Dakota to Texas.

We are now beginning to see the consequences of Red State hostility to health-care reform, and they are devastating for the poor. According to an April 2 report from the Kaiser Family Foundation (“The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid”), nearly 5 million people below the poverty line will now be ineligible both for Medicaid and for the subsidies available for the new health-care exchanges. The door to health-care coverage is doubly barred for the most vulnerable of our fellow Americans.

How can this be? We need to begin with a realistic picture of Medicaid. Many Americans believe all poor people already receive health-care coverage through Medicaid, just as all elderly people receive coverage through Medicare. But that’s not true. Most of the states that are refusing to expand Medicaid provide no coverage whatsoever to nondisabled adults who don’t have dependent children. And in many of these states, parents of dependent children don’t fare much better. Only the poorest of poor parents are covered. In Alabama, for instance, parents are covered only if their annual income does not exceed 16 percent of the federal poverty level—that’s $3,221 for a family of three. In Texas, the eligibility limit is 19 percent of the federal poverty level, which is particularly problematic given that state’s large uninsured population. The average cutoff for the twenty-four states that have refused to expand Medicaid is 46 percent of the federal poverty level, which is about $9,000 for a family of three.

And that’s not the worst of it. Many adults who exceed the state Medicaid limits are too poor to purchase insurance on the new health-insurance exchanges, which were designed to subsidize insurance for working and middle-class Americans making up to four times the poverty level. These insurance policies are completely unavailable to adults earning below the federal poverty level, because lawmakers assumed such people would be covered by the expansion of Medicaid. A family of three with a household income of more than $9,000 and less than $20,000 will be out of luck in many parts of the country.

Why did the Supreme Court strike down the Medicaid expansion mandate? In a nutshell, seven justices held that threatening the states with the loss of all their Medicaid funding unless they expanded the program was too “coercive,” and that it therefore exceeded Congress’s power under the Spending Clause. But the Spending Clause confers broad authority on Congress to distribute federal funds. No state is entitled to federal funds from year to year. And Congress regularly uses money as both a carrot and a stick to secure state compliance with federal programs. Given the fact that the federal government is subsidizing nearly all the costs of the Medicaid expansion, it’s hard to see this as constitutionally impermissible coercion.

Why did some states refuse to expand Medicaid? Most point to the cost of doing so. But that is short-sighted on the part of cost-conscious governors and legislatures. First, it now looks as though expanding Medicaid won’t cost as much as the federal government initially expected it to. Second, by expanding Medicaid, states avoid the cost of treating the uninsured in hospital emergency rooms, which is not only expensive but also breathtakingly inefficient. So it’s hard to make sense of the refusal to expand Medicaid on financial grounds; it looks more like ideological opposition to President Obama and health-care reform.

Let’s hope the poor in these states have better access to polling booths than they do to doctors. According to the Kaiser Foundation’s report, 86 percent of all poor, uninsured non-elderly adults fall into the Medicaid coverage gap. That’s not just a gap. That’s a sinkhole. The Supreme Court opened it up, and Red State governors and legislatures pushed their poor people into it.

About the Author

Cathleen Kaveny is the Darald and Juliet Libby Professor in the Theology Department and Law School at Boston College.

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The suggestion of the voting booth is reasonable, but coupled with the enormous spending now allowed that's sure to accompany the "powers that be" means less interest on the part of those most affected, I fear. I'm not sure how this current spiral downwards (see "Capital") ends, but I feel very pessimistic for our current democratic process.

 "it looks more like ideological opposition to President Obama and health-care reform."

 

The only agenda for the GOP for 5 years has been to oppose Obama at every turn, to prevent him from getting credit for anything. The country and its people have suffered because of this. 

 

I hope the Democrats make the high uninsured rates in red states the number one issue in the campaign.  It's a horrible, cynical scandal -- denying health care to poor people in pursuit of denying credit to a black President.

 

Larry Weisenthal/Huntington Beach CA

I see the infamous Bobby Jindal, Governor of Louisiana, is pictured above.  I hope that as this man begins his run for the U.S. Presidency, the rest of the nation will know the damage he has done to Louisiana.  Not only has he refused to accept additional Medicaid funds and denounced the Affordable Care Act, he privatized the charity hospital system in Louisiana (the LSU hospitals) that served the poor and the uninsured.  Most recently the CSM (Centers for Medicare and Medicaid Services) rejected his financial plan for the hospitals, leaving a huge hole in the state's budget.  The privatization is costing much more than anticipated; the private hospitals now are asking for millions more in over-run costs.

Add to this that Jindal has striped the university budgets by a whopping 60% or more in the last four or five years, a loss filled only by yearly rising tuition costs. While he likes to brag that he has not raised taxes, he ignores what he has done to the student population--most the first in their working class families.  By any other name, this higher tuition is a tax.

Jindal has ruined this state, and the nation needs to know that he has spent half of his two terms in office out of the state raising money for his fat war chest and campaigning ostensibly for other Republicans while actually putting himself repeatedly in the national limelight, all the while saying he has the job he wanted but clearly running higher office.

I have lived in Louisiana all my life (except for three years), and I think he is the worst governor we have had, and in Louisiana that is truly saying something.  

 

"it looks more like ideological opposition to President Obama and health-care reform."

It also looks like bigotry and hatred. Conservative Southern white men are furious because a black man had the audacity to run for president and win. Republicans nationwide make it clear on a regular basis that they loathe the poor. 

People will die as a result. Maybe Red State politicians should be reminded that some fetuses, embryos and zygotes will, too. Not that they really care about "life"--just about punishing and shaming women.

You're correct.  And what makes the opposition so insane is that "Obamacare" is basically Republican Mitt Romney's plan, designed to keep the insurance companies in business (which may or may not be a bad idea).  A few Republicans mouth the words that they want to design a new plan, but the truth is that they were in power for years and years, had all the opportunity in the world to do something, and instead sat on their hands.  

As others have noted, racism and a deep antipathy to any sort of "welfare" program are likely at the root of all this.

@ Michael Cassidy

"...a deep antipathy to any sort of 'welfare' program..."

Republicans have no antipathy to CORPORATE welfare.  

So the ACA turns out doing nothing for many of those who needed health care reform the most.  Now what's the follow-up from the Obama administration to try to fix or ameliorate this situation?  I see nothing.  Apparently the administartion is content that its "signature accomplishment"  looks like it's working (the press coverage is positive), and the needs of the very poorest among us are ignored again.

In Pennsylvania, Gov. Corbett did not expand Medicaid. Gov. Corbett turned his back on the most vunerable while he went to Rome to visit Pope Francis. Philadelphia Archbishop Caput should be ashamed for his part in getting the one minute audience with Pope Francis. The Pope was not fooled by Gov. Corbett's  misguide values. Thanks to informed voters, Tom Corbett will soon be a one term ex-governor.

Unfortunately, most white voters in red states, even the very poor, are quite sure they do not want Obamacare. Many do not know they would have qualified for Medicaid either. They do know, however, that they cannot buy it at the exchange because they cannot afford it which they view as Obama's fault.

The silence of the Roman Catholic Hierarchy is deafening. Shame. Perhaps it's time for we, the people of God, to occupy the Church. 

Re: Harold's remarks

I have long given up onthe American hierarchy as champions of any real change. True, they have somewhat supported immigration reform and the "border Mass" was a hopeful, but even that is suspect, I think. Statements and WITNESS are usually uninspired. They will not lead with anything to do with health care becasue of ppossible contamination with contraceptiona nd abortion issues.

Too many covering up too much mischief and protecting their own privilege and power. Judgment Day will be a too late harsh awakening. Reread Mathew 25:40

I think that the answer to this and similar issues is to keep the lines of communication open with people of other ideological positions.  I can make a great practical argument for the red states to expand medicaid, but it doesn't do any good if the only people listening are people who agree with me already.  It does a LOT of good if the people listening are Republican voters.

The argument I referenced is this:

If your state doesn't expand medicaid, you still pay federal taxes that pay for people to get insured when they can't afford it, but you don't get any of that money back.  Instead of getting it back, your legislators are giving it away. 

Now, some would argue that expanding medicaid benefits the lazy.  Since all of the expansion is going to people who work, that argument is not valid.  In fact, for people who are borderline disabled, but who choose to work, this expansion is a lifeline.  They may only be about 5% of the total of people who would benefit, but that's still a lot of people and it represents a huge amount of tax money if we force them all to take disability payments instead of working.  I work with a man who is disabled, chooses to work, and falls into that gap in Missouri.  His artificial leg collapsed at the knee a while back and he is now in a borrowed wheelchair.  He is in his early 60s and it takes him 15 minutes to get from the door to his desk and back.  For three weeks before someone rounded up a wheelchair for him, he was hopping on one leg.
 

There is also the issue of what will happen in 10 or 15 years when one of the states that doesn't expand this program has to compete for business with a state that did.  The ininsured areas of the country will have a large percentage of the existing untreated drug addicts and untreated mentally ill.  They will have a higher potential for epidemic outbreaks.  How is that going to be good for business?
 

 

I think that the answer to this and similar issues is to keep the lines of communication open with people of other ideological positions.  I can make a great practical argument for the red states to expand medicaid, but it doesn't do any good if the only people listening are people who agree with me already.  It does a LOT of good if the people listening are Republican voters.

The argument I referenced is this:

If your state doesn't expand medicaid, you still pay federal taxes that pay for people to get insured when they can't afford it, but you don't get any of that money back.  Instead of getting it back, your legislators are giving it away. 

Now, some would argue that expanding medicaid benefits the lazy.  Since all of the expansion is going to people who work, that argument is not valid.  In fact, for people who are borderline disabled, but who choose to work, this expansion is a lifeline.  They may only be about 5% of the total of people who would benefit, but that's still a lot of people and it represents a huge amount of tax money if we force them all to take disability payments instead of working.  I work with a man who is disabled, chooses to work, and falls into that gap in Missouri.  His artificial leg collapsed at the knee a while back and he is now in a borrowed wheelchair.  He is in his early 60s and it takes him 15 minutes to get from the door to his desk and back.  For three weeks before someone rounded up a wheelchair for him, he was hopping on one leg.
 

There is also the issue of what will happen in 10 or 15 years when one of the states that doesn't expand this program has to compete for business with a state that did.  The ininsured areas of the country will have a large percentage of the existing untreated drug addicts and untreated mentally ill.  They will have a higher potential for epidemic outbreaks.  How is that going to be good for business?
 

 

To the editor,

This showed an error when I hit "save" so I did it again.  Oops.

Not sure if my comment was deleted for some reason or if it just didn't save, but I'm glad Cathleen K. is writing about this issue.

Gist was that I thought Susan made an excellent point overall, but that mental health and substance abuse care are still undercovered, even with the improved ACA requirements. Also many employers have created more part-time positions to avoid paying for health care ... and that with those loss of hours, many employees have less purchasing power for premiums. 

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