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New York Times: 26 states decline federal aid to expand health care to the poor

The majority of those who would qualify for the Medicaid expansion will be blocked by their states from getting it, according to the Times.

The NYTimes has a jaw-dropping, crazy-making (but told in a voice of perfect objectivity) piece this a.m. about the 26 (26!) states that have still so far declined to participate in the feature of the Affordable Care Act that expands Medicaid to cover more poor and near-poor people who have no other way of affording health insurance.

Even though it’s sorta old news that some states were rejecting this option, the Times piece is the first systematic assessment of the impact, dripping with both hard numbers and human examples. I’ll just add a little background of how it fits into the bigger picture and excerpt a few of the Times’ big findings, but please click through and read the whole thing.

A little background

Rather than impose a sweeping but relatively simple program like single-payer health care, the architects of Obamacare tried to leave as much as possible of the existing U.S. health care system in place and add to it many provisions to provide coverage to those who lacked it. That’s one of reasons the law is so long and complicated.

One of the really big and fairly straightforward of those measures was to raise the income level for Medicaid. Medicaid already covers the very poor and the costs are shared by the states and the feds. Of all the categories of uninsured Americans, the biggest is probably those with lousy, low-paying jobs that don’t include health-insurance benefits but that pay just enough to disqualify employees from Medicaid. So Obamacare raised the limit on how much you could make and still qualify for Medicaid.

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Since the costs of Medicaid are shared between states and the feds, the law had to make it optional for states to participate. But, as written, the bill made the cost-sharing of the new Medicaid expansion extremely generous to the states, and then added a hammer provision that made it almost impossible for any states to opt out.

The generous part:  In the early years of the Obamacare era, the federal government would have borne the entire cost of the Medicaid expansion. After 2016, states would gradually have to chip in, but never more than 10 percent of the cost.

The hammer provision: States that opted not to participate would be deemed to have dropped out of Medicaid altogether and would lose billions of dollars that the feds were already contributing to insure the poorest of the poor in those states.

As you know, the U.S. Supreme Court (barely) ruled that the main parts of the law were constitutional but struck down that last hammer bit that would have thrown entire states off Medicaid if they rejected the expansion.

At the time I thought few if any states would reject the expansion, since the cost to the states themselves was such a small portion of the total. But I was wrong. Here’s some lowlights of what the Times found:


The states that have declined are “largely controlled by Republicans” and, although there are several in the North, they are concentrated in the southern states that also have above-average rates of poverty and above-average portions poor blacks. The only southern state that has so far decided to participate is Arkansas. Northern states that have so far declined the Medicaid expansion include Wisconsin, New Hampshire, Ohio and Pennsylvania, but the Times indicates that some of these are still considering opting in. Minnesota is in.

The line for qualifying for Medicaid is substantially lower than the official poverty line. So the decision of the states not to participate will leave, the Times found, “about eight million uninsured people who live in poverty ($19,530 for a family of three) without any assistance at all.”  

“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 [from assistance] are about 435,000 cashiers, 341,000 cooks and 253,000 nurses’ aides.”

I recommend the whole story. I’ll close with one of the Times’ human examples:

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Mississippi has the largest percentage of poor and uninsured people in the country — 13 percent. Willie Charles Carter, an unemployed 53-year-old whose most recent job was as a maintenance worker at a public school, has had problems with his leg since surgery last year.

His income is below Mississippi’s ceiling for Medicaid — which is about $3,000 a year — but he has no dependent children, so he does not qualify. And his income is too low to make him eligible for subsidies on the federal health exchange.

“You got to be almost dead before you can get Medicaid in Mississippi,” he said.

He does not know what he will do when the clinic where he goes for medical care, the Good Samaritan Health Center in Greenville, closes next month because of lack of funding.

“I’m scared all the time,” he said. “I just walk around here with faith in God to take care of me.”