Isn’t the federal Affordable Care Act supposed to help low-income Americans obtain the health insurance coverage that has been out of reach for millions? To be sure, that’s the idea at the heart of the law everyone now refers to as Obamacare. And despite frustrating hang-ups in online enrollment, the law will enable many folks to join the ranks of the insured.
Yet many other people who probably can’t afford any coverage at all will be flat out of luck. In North Carolina, the decision not to expand eligibility for Medicaid – expansion that was seen as a key Obamacare feature and lifeline – has resulted in the cruel irony that some of our neighbors are too poor to qualify for a program meant to help the poor.
Ours is one of 26 states that have exercised the prerogative granted by the U.S. Supreme Court not to enlarge their Medicaid programs despite the Affordable Care Act’s requirements. Conservative critics of the reform law, such as Gov. Pat McCrory and his fellow Republicans who control the General Assembly, view Medicaid as too expensive and don’t want to bring more people under that umbrella – even though the federal government would shoulder almost all of the cost.
So now North Carolinians paying federal taxes get to help pay for Medicaid expansion in other states. They also face health insurance premiums driven even higher by the cost of providing emergency and charity care to low-income, uninsured patients for whom Medicaid remains off-limits.
People who already have health insurance through their jobs won’t be sweating the details of Obamacare – unless, perhaps, they’ve gotten sick and are threatened with a loss of coverage, or are thinking about changing jobs and are worried about coverage for a pre-existing condition. Under the new law they’ll have some protection.
For those who have to buy health insurance on their own, not through their place of work, the law offers tax credits subsidizing the cost – provided the buyer’s income is above the federal poverty level. But for people who make little money, coverage will be hard to afford even with subsidies. So Obamacare is designed to bring those whose income is no more than 138 percent of the poverty level – just shy of $27,000 for a family of three – under Medicaid.
A hurtful fall
Uncooperative states, such as North Carolina, are left with many people who qualify neither for subsidies nor for Medicaid as the program now operates. They fall into a “coverage gap” that wouldn’t exist but for the senseless, heartless decision by the legislature and governor to deprive them of help they were supposed to get.
Medicaid is a crucial safety net for low-income parents and the disabled. But in North Carolina a non-disabled, poor adult without dependent children isn’t covered.
If he or she needs to see a doctor, it’s off to the charity clinic or the hospital emergency room, where the costs of care end up being shifted to patients with insurance. Needless to say, the ongoing level of medical attention such a person receives typically doesn’t match what an insured patient expects. Health consequences can be serious.
The Kaiser Family Foundation figures that more than five million low-income Americans who would be brought under Medicaid if states expanded their programs instead will remain in the coverage gap. In North Carolina 318,710 people will be affected, the foundation estimates. Click here to read the group’s recent brief.
Kaiser’s breakdown paints a stark picture of poverty-stricken North Carolinians for whom regular health care must seem like a dream. To qualify for Medicaid, a family of three can have an annual income no higher than $8,861. Without children living at home, non-disabled adults don’t qualify, period.
According to Kaiser, those 318,710 folks in the coverage gap represent 28 percent of all North Carolinians without health insurance (taking senior citizens, who are eligible for Medicare, out of the equation).
They also represent 58 percent of the state’s low-income, uninsured adults, defined as those with annual earnings no greater than 138 percent of the poverty level. And they represent a stunning 91 percent of those who make no more than 100 percent of the poverty level – in other words, the really poor.
Think about it – even with the Affordable Care Act now in effect, 91 percent of North Carolinians in most desperate need of health insurance coverage still won’t find it the slightest bit easier to get! No wonder the NC Council of Churches regards Medicaid expansion, along with broader access to affordable health care in general, as a core social justice issue.
Hospitals on the edge
The state’s hospitals, especially those that count on a flow of Medicaid reimbursements to help them meet expenses, have favored the program’s expansion. And they’ve warned that having to cope with an ongoing stream of uninsured patients could drag them down.
Vidant Health’s 60-bed hospital in Belhaven, north of the Pamlico River in Beaufort County, was struggling financially with an aging facility even before the Medicaid decision in Raleigh. But having to do without more Medicaid revenue appears to be one reason why Vidant, despite community protests, has scheduled the hospital to close. It will be replaced by a multi-specialty, around-the-clock clinic, but there will be no in-patient beds.
North Carolina has done good work trying to upgrade the level of health care in its small towns and rural counties. The medical school at East Carolina University, for example, has been at the forefront of this effort. But a refusal to let the Affordable Care Act work as it was intended now represents backsliding that poses actual harm to many of the state’s low-income residents. Count those who have relied on access to the hospital in Belhaven as also among those bearing the burden of state leaders’ obstinacy.
Gov. McCrory could go far toward atoning for some of his first-year misjudgments if he would acknowledge the benefits of Medicaid expansion and put it back on the agenda for the legislature to consider. The health insurance coverage gap as it now stands in North Carolina is unnecessary, inhumane and a disgrace to the state’s good name.
