Because of last year's Supreme Court decision on the Affordable Care Act (ACA) (aka “Obamacare”), the law's principal goal of providing health care to Americans who are too poor to afford insurance yet ineligible for government assistance will not be met for more than half of them.

As originally passed by Congress, the ACA was intended to work along two principal tracks. First, those who earn more than the federal poverty line ($11,500 for an individual) but less than four times that amount and who can't get coverage at work were to be able to use government subsidies to shop for a health plan on the new exchanges. Second, those who earn less than the poverty line were to get insurance via expanded eligibility for Medicaid programs.

When the Supreme Court ruled that states could choose to reject the Medicaid expansion, it left the first track intact, but made the success of the Medicaid expansion dependent on state-level decisions. The result so far—and states still have several months to decide—has followed partisan politics almost perfectly.

At least 25 states—almost exclusively those with Republican governors or Republican-controlled legislatures—have resisted expanding the program, while states where Democrats are in charge have decided to enact the expansion, which will be paid for entirely by the federal government for the first few years and 90% after that. 

Ironically, the states that are rejecting the Medicaid expansion are those whose citizens could use it most, as more than half of all those without health insurance live in such states. As a result, according to the Urban Institute, about 5.7 million uninsured adults below the poverty line will not get health coverage through the expansion. 

The upside-down nature of this outcome was explained by Jonathan E. Chapman, executive director of the Louisiana Primary Care Association, this way: “If the breadwinner in a family of four works full time at a job that pays $14 an hour and the family has no other income, he or she will be eligible for insurance subsidies. But if they make $10 an hour, they will not be eligible for anything.”

Bruce Lesley, the president of the child advocacy group First Focus, emphasized that most poor people are not aware of the anomaly: “In states that do not expand Medicaid, some of the neediest people will not get coverage. But people who are just above the poverty line or in the middle class can get subsidized coverage. People will be denied assistance because they don’t make enough money. Trying to explain that will be a nightmare.”

Actually, the decision is easy to explain…from a political point of view. Republican Party leaders have taken the position that if any good comes out of Obamacare, the Democrats will get the credit, so it is better to sabotage it whenever possible. In addition, poor people rarely vote for Republicans anyway, so helping them is not an electoral priority.

From a public health viewpoint, the rejection of Medicaid expansion will probably widen the divide between the rich and poor in those states and between them and states that okay the expansion. Take Massachusetts and Texas. In Massachusetts, about 94% of adults under 65 have health coverage, the highest rate in the nation, while only 68% of working-age Texans are insured, the lowest rate. Not surprisingly, the rate of potentially preventable deaths is 36% higher in Texas than in Massachusetts, according to data from the Centers for Disease Control and Prevention.

-Matt Bewig

To Learn More:

States’ Policies on Health Care Exclude Some of the Poorest (by Robert Pear, New York Times)

Medicaid Opposition Underscores States' Healthcare Disparities (by Noam N. Levey, Los Angeles Times)

Florida Rejects Medicaid Expansion, Leaves 1 million Uninsured (by Sarah Kliff, Washington Post)

30% of Doctors Will Refuse to Treat New Medicaid Patients (by Noel Brinkerhoff, AllGov)

Disabled Idahoans Sue State over Medicaid Cuts the State Refuses to Explain (by Matt Bewig, AllGov)