Note: Originally posted at The McLean Parlor.
It’s now more than a full week into the new year and a moment that many have either celebrated or feared is well underway: the (almost) full implementation of the Affordable Care Act. While seven days may not be enough time to enact the worst fantasies from the health care law’s opponents, it has been enough time to begin talking about the imperfect reality of health care reform in 2014. The numbers for enrollment are understandably hazy but accounting for signups to the state and federal exchanges, as well as those individuals under 26 covered through a parent’s policy, as of December 31st at least 5.2 million people have gained coverage thanks to the new law. Adding some unknown (though still probably large) portion through 4.4 million in Medicaid brings the total number closer to nine or ten million people.
Whatever the actual number the ACA is a rock-solid reality for everyone. It’s also an unequal reality for too many. As Kaiser Health News reported yesterday, some 140,000 in five states alone are in limbo due to software delays in processing their new insurance coverage. For those individuals such insurance will be unacceptably late, but for a much larger number of Americans coverage may not materialize at all. So while the benefits are real and substantial, so are their absence.
As I mentioned in my end-of-the-year post I’m now living in the state of Florida. While the state has many things to offer — beaches, theme parks, 23.5 lightning strikes per square mile — one thing it’s not offering right now is the full range of benefits from the ACA. According to a new issue brief from the Kaiser Family Foundation, decisions made by the state will create a new disparity in insurance coverage (emphasis in bold mine):
The ACA establishes coverage provisions across the income spectrum, with the expansion of Medicaid eligibility for adults serving as the vehicle for covering low-income individuals and premium tax credits to help people purchase insurance directly through new Health Insurance Marketplaces serving as the vehicle for covering people with moderate incomes. With the June 2012 Supreme Court ruling, the Medicaid expansion became optional for states, and as of December 2013, Florida was not planning to implement the expansion. As a result, many uninsured adults in Florida who would have been newly-eligible for Medicaid will remain without a coverage option.
As the report explains, the health care law was designed to provide insurance coverage through an expanded Medicaid program for most non-elderly adults with income below 138 percent of the federal poverty line ($19,530 for a family of three in 2013). Incomes between 100 and 400 percent of FPL were to be eligible for tax subsidies when purchasing coverage on the new exchanges. Yet as a result of the Supreme Court decision several states, including Florida, have so far declined the expansion. Without a post-decision legislative fix people whose income fall between existing Medicaid eligibility standards and the threshold for tax credits fall into a new ‘gap’ — too wealthy to qualify for the traditional Medicaid program and too poor to receive credit assistance on the exchanges.
Here is the overall picture of the uninsured in the state of Florida:
From the KFF report there are about 3.9 million uninsured Floridians. Thanks to the ACA about 1.3 million of those (33 percent) now qualify for financial assistance to purchase private coverage in the federally-run insurance exchange. Another 23 percent will either earn too much to qualify for tax credits or be offered coverage through an employer-sponsored plan. The next largest segment (20 percent) of the uninsured fall into the coverage gap; 764,000 people, who if not for political decisions made by state legislatures would be gaining a modicum of health care security and access through Medicaid. Including, incidentally, myself and my wife.
So what can we and over three-quarters of a million other Floridians in the coverage gap expect in 2014? According to The Advisory Board, absolutely nothing. The Florida legislature, despite previous support from Republican Governor Rick Scott, has no plan to address the absence of an expanded Medicaid program. As Harold Pollack wrote in his prediction for how the ACA will fare in 2014, and I happen to agree, it is “important that these recalcitrant officials pay some price—not just to smooth the way for expanded coverage, but to debunk a particularly toxic assumption in American life. Too many politicians assume that poor people just don’t matter, politically.” On November 4th of this year we’ll have an opportunity to alter those assumptions.