Millions of Poor Are
Left Uncovered by Health Law
James
Patterson for The New York Times
Claretha
Briscoe, left, of Hollandale, Miss., with family. She earns too much to qualify
for Medicaid but not enough to get subsidies on the new health exchange.
Because they live in states largely controlled by
Republicans that have declined to participate in a vast expansion of Medicaid,
the medical insurance program for the poor, they are among the eight million
Americans who are impoverished, uninsured and ineligible for help. The federal
government will pay for the expansion through 2016 and no less than 90 percent
of costs in later years. A sweeping national effort to extend health
coverage to millions of Americans will leave out two-thirds of the poor blacks and
single mothers and more than half of the low-wage workers who do not have
insurance, the very kinds of people that the program was intended to help,
according to an analysis of census data by The New York Times.
Those excluded will be stranded without insurance, stuck
between people with slightly higher incomes who will qualify for federal
subsidies on the new health exchanges that went live this week, and those who
are poor enough to qualify for Medicaid in its current form, which has income
ceilings as low as $11 a day in some states.
People shopping for insurance on the health exchanges are
already discovering this bitter twist.
“How can somebody in poverty not be eligible for
subsidies?” an unemployed health care worker in Virginia asked through tears.
The woman, who identified herself only as Robin L. because she does not want
potential employers to know she is down on her luck, thought she had run into a
computer problem when she went online Tuesday and learned she would not
qualify.
At 55, she has high blood pressure, and she had been
waiting for the law to take effect so she could get coverage. Before she lost
her job and her house and had to move in with her brother in Virginia, she
lived in Maryland, a state that is expanding Medicaid. “Would I go back there?”
she asked. “It might involve me living in my car. I don’t know. I might
consider it.”
The 26 states that have rejected the Medicaid expansion are
home to about half of the country’s population, but about 68 percent of poor,
uninsured blacks and single mothers. About 60 percent of the country’s
uninsured working poor are in those states. Among those excluded are about
435,000 cashiers, 341,000 cooks and 253,000 nurses’ aides.
“The irony is that these states that are rejecting
Medicaid expansion — many of them Southern — are the very places where the
concentration of poverty and lack of health insurance are the most acute,” said
Dr. H. Jack Geiger, a founder of the community health center model. “It is
their populations that have the highest burden of illness and costs to the
entire health care system.”
The disproportionate impact on poor blacks introduces the
prickly issue of race into the already politically charged atmosphere around
the health care law. Race was rarely, if ever, mentioned in the state-level
debates about the Medicaid expansion. But the issue courses just below the
surface, civil rights leaders say, pointing to the pattern of exclusion.
Every state in the Deep South, with the exception of
Arkansas, has rejected the expansion. Opponents of the
expansion say they are against it on exclusively economic grounds, and that the
demographics of the South — with its large share of poor blacks — make it easy
to say race is an issue when it is not.
In Mississippi, Republican leaders note that a large
share of people in the state are on Medicaid already, and that, with an
expansion, about a third of the state would have been insured through the
program. Even supporters of the health law say that eventually covering 10
percent of that cost would have been onerous for a predominantly rural state
with a modest tax base.
“Any additional cost in Medicaid is going to be too
much,” said State Senator Chris McDaniel, a Republican, who opposes expansion.
The law was written to require all Americans to have
health coverage. For lower and middle-income earners, there are subsidies on
the new health exchanges to help them afford insurance. An expanded Medicaid
program was intended to cover the poorest. In all, about 30 million uninsured
Americans were to have become eligible for financial help.
But the Supreme Court’s ruling on the health care law
last year, while upholding it, allowed states to choose whether to expand
Medicaid. Those that opted not to leave about eight million uninsured people
who live in poverty ($19,530 for a family of three) without any assistance at
all.
Poor people excluded from the Medicaid expansion will not
be subject to fines for lacking coverage. In all, about 14 million eligible
Americans are uninsured and living in poverty, the Times analysis found.
The federal government provided the tally of how many states
were not expanding Medicaid for the first time on Tuesday. It included states
like New Hampshire, Ohio, Pennsylvania and Tennessee that might still decide to
expand Medicaid before coverage takes effect in January. If those states go
forward, the number would change, but the trends that emerged in the analysis
would be similar.
Mississippi has the largest percentage of poor and
uninsured people in the country — 13 percent. Willie Charles Carter, an
unemployed 53-year-old whose most recent job was as a maintenance worker at a
public school, has had problems with his leg since surgery last year.
His income is below Mississippi’s ceiling for Medicaid —
which is about $3,000 a year — but he has no dependent children, so he does not
qualify. And his income is too low to make him eligible for subsidies on the
federal health exchange.
“You got to be almost dead before you can get Medicaid in
Mississippi,” he said.
He does not know what he will do when the clinic where he
goes for medical care, the Good
Samaritan Health Center in Greenville, closes next
month because of lack of funding.
“I’m scared all the time,” he said. “I just walk around
here with faith in God to take care of me.”
The states that did not expand Medicaid have less
generous safety nets: For adults with children, the median income limit for
Medicaid is just under half of the federal poverty level — or about $5,600 a
year for an individual — while in states that are expanding, it is above the
poverty line, or about $12,200, according to the Kaiser Family Foundation.There
is little or no coverage of childless adults in the states not expanding,
Kaiser said.
The New York Times analysis excluded immigrants in the
country illegally and those foreign-born residents who would not be eligible
for benefits under Medicaid expansion. It included people who are uninsured
even though they qualify for Medicaid in its current form.
Blacks are disproportionately affected, largely because
more of them are poor and living in Southern states. In all, 6 out of 10 blacks
live in the states not expanding Medicaid. In Mississippi, 56 percent of all
poor and uninsured adults are black, though they account for just 38 percent of
the population.
Dr. Aaron Shirley, a physician who has worked for better
health care for blacks in Mississippi, said that the history of segregation and
violence against blacks still informs the way people see one another,
particularly in the South, making some whites reluctant to support programs
that they believe benefit blacks.
That is compounded by the country’s rapidly changing
demographics, Dr. Geiger said, in which minorities will eventually become a
majority, a pattern that has produced a profound cultural unease, particularly
when it has collided with economic insecurity.
Dr. Shirley said: “If you look at the history of
Mississippi, politicians have used race to oppose minimum wage, Head Start, all
these social programs. It’s a tactic that appeals to people who would rather
suffer themselves than see a black person benefit.”
Opponents of the expansion bristled at the suggestion
that race had anything to do with their position. State Senator Giles Ward of
Mississippi, a Republican, called the idea that race was a factor
“preposterous,” and said that with the demographics of the South — large shares
of poor people and, in particular, poor blacks — “you can argue pretty much any
way you want.”
The decision not to expand Medicaid will also hit the
working poor. Claretha Briscoe earns just under $11,000 a year making fried
chicken and other fast food at a convenience store in Hollandale, Miss., too
much to qualify for Medicaid but not enough to get subsidies on the new health
exchange. She had a heart attack in 2002 that a local hospital treated as part
of its charity care program.
“I skip months on my blood pressure pills,” said Ms.
Briscoe, 48, who visited the Good Samaritan Health Center last week because she
was having chest pains. “I buy them when I can afford them.”
About half of poor and uninsured Hispanics live in states
that are expanding Medicaid. But Texas, which has a large Hispanic population,
rejected the expansion. Gladys Arbila, a housekeeper in Houston who earns
$17,000 a year and supports two children, is under the poverty line and
therefore not eligible for new subsidies. But she makes too much to qualify for
Medicaid under the state’s rules. She recently spent 36 hours waiting in the
emergency room for a searing pain in her back.
“We came to this country, and we are legal and we work
really hard,” said Ms. Arbila, 45, who immigrated to the United States 12 years
ago, and whose son is a soldier in Afghanistan. “Why we don’t have the same
opportunities as the others?”
Courtesy:
http://www.nytimes.com/2013/10/03/health/millions-of-poor-are-left-uncovered-by-health-law.html?pagewanted=all&_r=1&
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