Where congressional Republicans have had limited success in doing serious damage to Obamacare, John Roberts' Supreme Court might just succeed. That's because their ruling that states could refuse to expand Medicaid under the law will leave many uninsured people just that: uninsured. That's because there's a gap in the income levels set between Medicaid eligibility under the law, and when federal subsidies kick in. In the 26 states that have so far either refused the expansion or not decided, as many as two in five uninsured adults fall into that gap, according to a new study from the Commonwealth Fund.
Between 2010 and 2012, nearly one-third (32%) of U.S. adults ages 19 to 64, or an estimated 55 million people, were either continuously uninsured or spent a period of time uninsured. Data from the 2011 and 2012 Commonwealth Fund Health Insurance Tracking Surveys of U.S. Adults show that people with incomes below 133 percent of the federal poverty level (i.e., the level that will make them eligible for Medicaid in 2014 under the Affordable Care Act) were uninsured at the highest rates. Yet, fewer than half the states are currently planning to expand their Medicaid programs, because the 2012 Supreme Court decision allows states to choose whether to expand eligibility. In those states that have not yet decided to expand, as many as two of five (42%) adults who were uninsured for any time over the two years would not have access to the new coverage provisions in the law.What's more, those states that are refusing the expansion have the most uninsured, the survey found. "[I]n the 26 states that have said they are not expanding or are undecided, nearly three-quarters (72%) of adults with incomes below 133 percent of poverty in one or both of the two years spent a time uninsured over the two-year period." That's opposed to 61 percent of those surveyed in the states that will be expanding Medicaid.
The survey identified another problem for low-income Americans trying to get health insurance under the new law in the refusing states—fluctuating incomes. Twenty-nine percent of the surveyed population had income levels that fluctuated enough in those two years to change their eligibility for subsidies. So one year they could qualify, the next year they could lose the subsidy, fall into the gap, and lose insurance altogether. There's a fix, Commonwealth says, for both of these problems, but it's an unlikely one since it requires Congress.
Congress needs to pass a bill to expand the subsidy program, allowing adults below the poverty line who are not eligible for Medicaid to get the subsidy. As long as we're asking the Congress to do this, we might as well be asking the Congress to make a real, substantive reform by opening up Medicare to these people. Neither is likely to happen as long as Republicans control the House of Representatives. The solution is going to require organizing at the state level to both pressure governors and legislatures who have refused the expansion to change their minds, either by lobbying or by ousting them in 2014.