The coverage gap

As you may know, the intent of the Affordable Care Act was to get people below a certain income level onto Medicaid, with people at or above that income level receiving subsidized health insurance via the exchanges. Unfortunately, when the Supreme Court ruled that the Medicaid expansion mandate was unconstitutional, it meant that in states that refused to expand Medicaid people who fell below that income level but above the income level for Medicaid eligibility as things were would be left out of coverage – too poor to receive insurance subsidies, not poor enough for Medicaid. More than one million Texas adults fall into that coverage gap. Here’s a story about one of them.

It’s constitutional – deal with it

Damaged discs in Irma Aguilar’s neck make it hard to raise her arms, something she must do repeatedly when stacking boxes at the pizza restaurant where she earns $9 an hour as an assistant manager.

Sometimes, her untreated high blood pressure makes her so dizzy she has to grab onto something to prevent a fall.

And she struggles with anxiety, a heart-pounding fear that can strike at any time, but especially at night, when she lies in bed and wonders how she’s going to make ends meet.

Without insurance, she worries about how she will find the money to treat her health problems, which threaten her livelihood and the well-being of her family.

[…]

Aguilar’s four children are covered by Medicaid, which provides free or reduced-cost health care. But Aguilar makes too much money – $19,200 a year – to qualify. Texas’ Medicaid eligibility requirements are among the tightest in the nation, and Aguilar has to be nearly destitute to meet them – making no more than $4,200 a year as head of a family of five.

Emphasis mine. What that means is that if you make more than two dollars an hour working fulltime, you make too much money as the head of a family of five to qualify for Medicaid in Texas. Think about that for a minute.

Still left out of Medicaid, Aguilar hoped to get insurance under the ACA, but to qualify for a tax credit to help her pay for it, she would need to earn more than she does – at least $27,570 a year. Only those earning between 100 percent and 400 percent of the poverty level are eligible for the subsidies. Aguilar is at 70 percent.

This puts her in the gap, with neither Medicaid nor affordable health insurance.

If she could get a subsidy, Aguilar would have shelled out about $46 a month for a midlevel health plan. Without one, the cost would have zoomed to more than $200 a month, a price that puts health insurance out of her reach.

“I have to scrape by as it is,” Aguilar said. “By the time I pay rent, lights and water, there’s not much left over. Sometimes, I don’t eat so my kids can eat.”

[…]

As Texas rejected the extra Medicaid money, state lawmakers committed more resources to health care in the past session, said Stephanie Goodman, a spokeswoman with the Texas Health and Human Services Commission.

The Legislature set aside $100 million in added money for primary care services for women and an additional $332 million for mental health services, she wrote in an email.

“We’ve also developed a strong network of health centers across the state that provides low-income citizens with access to both preventive care and treatment for medical issues,” she said.

Such clinics depend on a mix of revenue – Medicaid, private insurance and patient fees – to enable them to provide care to those who lack insurance.

But those front-line providers don’t have enough money and resources to care for all the uninsured, including those in the coverage gap, said José Camacho, head of the Texas Association of Community Health Centers.

Nor can health centers provide a broad range of services, making them a too-porous safety net, others say.

“They’re no substitute for not having coverage,” said Anne Dunkelberg, a policy analyst at the Center for Public Policy Priorities, which advocates for low-income Texans. “They can’t provide specialty treatment or trauma care. If you’ve been hurt in a car wreck or have a broken bone or cancer, if you need a CT scan, you’re going to be out of luck. Health centers are wonderful for primary care, but they’re not a substitute for comprehensive care.”

Ms. Aguilar has chronic conditions, as noted above, so these health centers likely wouldn’t be of much good to her anyway, assuming she could afford their fees. Even if she could, she wouldn’t be able to afford any medications they might prescribe. So she’s pretty much SOL. I personally think that Rick Perry, David Dewhurst, Greg Abbott, Dan Patrick, Ted Cruz, and everyone else responsible for Texas’ horrible lack of health insurance for so many of its residents should be made to personally explain to Ms. Aguilar and her kids why they don’t want her to be able to get health care. Not that I think it would have any effect on them, but maybe if they had to explain it to all one million plus Texans that they have excluded from coverage it might eventually wear them down.

I do know one way that Ms. Aguilar and the million others like her could get helped, and that’s by electing Wendy Davis and Leticia Van de Putte this November. No guarantee that they’d be able to overcome legislative resistance, of course, but there was some sentiment for expansion in 2011, and at least they wouldn’t be adding to that resistance. And if the Lege still can’t stand the idea of expanding Medicaid, there’s another way they could help Ms. Aguilar and many others like her: Raise the minimum wage. If Ms. Aguilar earned a bit more than $13 an hour, then her fulltime salary would make it to that magic $27,500 level – which is to say, exactly at the federally defined poverty line – and she’d qualify for insurance subsidies on the exchange. Either way would be fine by me.

Related Posts:

• Perry keeps asking for the same Medicaid waiver he hasn’t gotten in the past
• If Medicaid is broken, who broke it?
• A different push for health care expansion