The Red State ACA Donut Holes

North Carolina, like many states controlled by Republicans, opted out of the Medicaid-expansion component of the Affordable Care Act. A New York Times article explores the practical effect it's having on those states' citizens:

A sweeping national effort to extend health coverage to millions of Americans will leave out two-thirds of the poor blacks and single mothers and more than half of the low-wage workers who do not have insurance, the very kinds of people that the program was intended to help, according to an analysis of census data by The New York Times.

Because they live in states largely controlled by Republicans that have declined to participate in a vast expansion of Medicaid, the medical insurance program for the poor, they are among the eight million Americans who are impoverished, uninsured and ineligible for help. The federal government will pay for the expansion through 2016 and no less than 90 percent of costs in later years.

Those excluded will be stranded without insurance, stuck between people with slightly higher incomes who will qualify for federal subsidies on the new health exchanges that went live this week, and those who are poor enough to qualify for Medicaid in its current form, which has income ceilings as low as $11 a day in some states…

The 26 states that have rejected the Medicaid expansion are home to about half of the country’s population, but about 68 percent of poor, uninsured blacks and single mothers. About 60 percent of the country’s uninsured working poor are in those states. Among those excluded are about 435,000 cashiers, 341,000 cooks and 253,000 nurses’ aides.

“The irony is that these states that are rejecting Medicaid expansion — many of them Southern — are the very places where the concentration of poverty and lack of health insurance are the most acute,” said Dr. H. Jack Geiger, a founder of the community health center model. “It is their populations that have the highest burden of illness and costs to the entire health care system.”

We're going to be hearing a LOT about the ACA, aka Obamacare, rollout over the next few months. The program opened for enrollment on Tuesday (Oct 1) with a start date set for January and the traffic to the website was heavy enough that it slowed to a crawl.  Like any new program, especially one of this scale, there will be issues but it will be interesting to see if the overall benefits outweigh the problems enough that people will eventually say "Keep the government's hands off my ACA!"

If that does happen it will be with folks like the self-employed who couldn't get on a regular insurance plan that was anywhere near affordable, the employees working for small employers who stopped offering health insurance long ago because they couldn't afford to provide coverage and weren't legally required to, and the folks with preexisting conditions who couldn't get any coverage no matter how much they were willing to spend. Sadly it seems that a huge chunk of the working poor will fall in the "not poor enough" donut hole created by states' refusal to expand Medicaid and won't have access to a program that was most definitely intended for them.

As you can likely tell I'm one of those who is truly hoping that ACA is a step in the right direction for our country. I don't believe it's a silver bullet or that it truly fixes anything, but I'm hoping that it's a step in the direction of a comprehensive, effective reform of our health care system. It's still way too early to see what the end result of ACA is going to be, but quite frankly it would be hard to go backwards from where we've been in the recent past so I'm pretty confident it will be a net benefit for society. On the other hand I seriously doubt it's enough on its own and I hope we continue to look for ways to make sure the neediest have some form of health coverage without bankrupting the rest of us in the process.

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