Behold the Medicaid Gap – not a geological schism, but a political one. a bureaucratically suave vestige of a Jim Crow mentality that most Americans thought had receded into history texts. But racism smolders, not so deep within the American psyche. This time it is once again cloaked in a reverence for states’ rights, specifically the right of states to snub their nose at Uncle Sam. A passion for ultra-conservatism gives states cover for the snub. And perhaps the fact that our President is African-American lends oomph to the fervor.
The impact of Jim Crow laws was to bar poor African Americans from voting booths. The disparate impact of this bureaucratic decision is to bar poor African Americans from the doctors, hospitals, and drugs that most Americans, thanks to the Affordable Care Act, will soon take for granted.
The Act sought to bring all Americans under the umbrella of an insurance policy that would be both comprehensive and affordable – a double whammy that does not happen naturally. Before the Affordable Care Act, a plethora of insurers offered policies that were either too expensive for the people who needed them, or too minimal to help anybody even mildly ill. We dubbed those insured enrollees who couldn’t truly access care “underinsured.” We hoped that the concept would slink into a linguistic archive, with words like “pre-existing condition.”
Under the Affordable Care Act, the federal government expected states to expand Medicaid. Uncle Sam offered states generous incentives for the expansion. Residents who didn’t qualify for Medicaid would, ideally, be covered under an employer’s policy, or would enroll in one of the approved policies. Depending upon income, an enrollee would get a subsidy to defray the costs of the premiums.
But 23 states refused to expand Medicaid, despite federal subsidies. What happens to people shut out from the expansion? On the one hand, they cannot join their state’s Medicaid rolls, as the Affordable Care Act had presumed. On the other hand, their incomes are too low for the “marketplace” subsidies available under the Act. Those residents fall into “the Medicaid gap.”
Today, roughly 4 million people fall into this gap. Most live in the South. One quarter live in Texas (the state with the highest percentage of uninsured). In Wisconsin nobody falls into the gap, because the state is providing Medicaid eligibility to adults up to the poverty level, but not up to 138% of the poverty level, as the ACA allows. However, those above the poverty level qualify for insurance subsidies.
Sarah Varney spotlighted the impact on Mississippi, “How Obamacare Went South In Mississippi,” Oct. 29, 2014, in Kaiser Health News.
Mississippi comes out on the nation’s statistical top, or bottom, depending on vantage: the lowest per-capita income, the highest rate of illiteracy, the lowest life expectancy, the highest rate of premature births, the highest rate of leg amputations, (4.412 per 1000 Medicare enrollees for black Mississippians, 0.92 for whites). In a state dominated by small businesses, many residents are uninsured. Yet after the Affordable Care Act, even more residents are uninsured (another national prize for the state): one in 3 African-Americans, one in five whites.
Despite the widespread illness, the widespread poverty, Tea Party enthusiasts blocked an expansion of Medicaid (even though the expansion would not initially drain state coffers, would enhance the health of residents, would prop up the state’s hospitals). The state decided: only parents, or pregnant women, with very low incomes ($384 a month for a family of three) could enroll. The state’s wait-staff, truckers, factory workers, retail clerks were told they had to enroll in health insurance: the federal government was forcing them to. But the sign-up was cloaked in confusion and misinformation, as competing factions in a state that loathed the Affordable Care Act battled for power. And the economics of the gap loomed: Some residents would face premiums they couldn’t afford, with deductibles as high as $6,000, and high co-pays. Meanwhile, the state’s hospitals lost the money they would have reaped under a Medicaid expansion; some hospitals shuttered departments.
Poor residents – many of whom are African-Americans, many of whom are ill – discovered that Uncle Sam would not help.
On the silver-lining horizon, recently the governor of Alabama – a state in the running for some statistical highs – cautiously “cracked open the door” to expanding Medicaid, perhaps linking it to employment.
Sometimes the arc of the moral universe moves toward justice, but at a glacial pace.
Joan Retsinas is a sociologist who writes about health care. Email retsinas@verizon.net.
From The Progressive Populist, February 1, 2015
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