On the coverage gap
Peace and Security Research and Policy Intern
November 2016- June 2017
A third-year student at Tulane University in New Orleans, the city that has her heart, Hanan is studying Neuroscience and Public Health with career goals either in international law or palliative care. To keep well-adjusted, Hanan balances her mostly science-leaning course load with well-developed outside interests, ranging from elderly care to refugee relief, writing, and travel. Hanan is passionate about finding creative ways to uplift traditionally silenced voices, and is super excited for the opportunity of mentorship from Dr. Murabit!
Imagine being too poor to qualify for help.
Although President Trump’s foreboding prediction that Obamacare is going to “implode” is overstated, in typical Trump fashion, Obamacare in its current form is far from perfect. Rising costs have monopolized national discourse vis-à-vis the shortcomings of Obamacare.
But there is something, that isn’t as much the fault of Obamacare as it is the shortsightedness of the Supreme Court who unwittingly gave the green light, that generates the most frustration and confusion in me: the so-called coverage gap.
Before understanding what the coverage gap is, one must quickly review some fundamental features of Obamacare. One of Obama’s priorities was to increase the affordability of healthcare, thereby enabling more people to have access to it. He did this by offering subsidies to people making approximately between $11,500 and $46,000 a year. The allocation of subsidies was done intuitively: the poorer the individual and the costlier health insurance in his or her respective state, the more help that individual received. Premiums caps were established so that subsidies would rise with rising premiums to ensure that people would not be subjected to the volatile ebbs and flows of healthcare costs. People making more than roughly $46,000 a year were essentially deemed financially stable enough to be able to afford insurance.
This, of course, is not necessarily the case, or even ballpark the fact of the matter. The difference between someone making $46,000 and $47,000 annually is negligible, and both earners are arguably not financially well-situated enough to afford the worrisomely high healthcare costs that seem to only be rising. Yet one is offered help and the other is not. Still, the dividing line has to be put somewhere, and it would seem arbitrary wherever it is placed.
What about the folks making less than $11,500? Obama and his team didn’t leave those people out. To account for the poorest individuals, they expanded Medicaid. Prior to the Affordable Care Act, only certain populations could qualify for Medicaid. People who had no children, no matter how shallow their pockets, could never qualify, since they were not among, to use a mouthful of a phrase, “categorically eligible populations.”
There were even troublesome gaps for some Medicaid-eligible populations such that the cut-off meant that you had to be nearly homeless and hungry to qualify. Recognizing these hugely problematic gaps in coverage, the Obama administration expanded Medicaid so that all people under age 65 who had incomes below roughly $11,500 could get it.
Some Americans could never imagine what it would be like to live without something as essential and basic as healthcare. So it is not too surprising that a number of people thought Medicaid expansion was unconstitutional, since Medicaid started off as a voluntary program. The case reached the Supreme Court, and the majority opinion was that Medicaid expansion should be optional. This meant that states could henceforth decide whether or not they would choose to expand their Medicaid program.
But what states would be silly enough to pass up an offer so dazzling? Until 2020, the federal government would be fully shouldering the additional costs accrued from Medicaid expansion. After that, they’d be covering all but a tenth of the expense. With a deal like that (the most irresistible bargain that I’ve personally ever found), it seems hard to understand why any reasonable state government wouldn’t quickly snatch it.
Except some states didn’t. And it wasn’t just a handful of rogue states that decided to spurn the glittery offer. To date, thirty-two states, including Washington, D.C., have expanded Medicaid, leaving a whopping nineteen which haven’t. In these latter states, the people that Medicaid expansion was created with in mind have been left out in the cold, pretty much forced to fend for themselves.
For these two and a half million people, the seemingly too-lopsided-to-be-plausible thought experiment we did at the outset is now reality. They’re in one of the most perplexing and exasperating situations to date: they are, yes, too poor to get help.
Considering the magnitude of the problem, it’s bewildering that more people aren’t raising hell about the coverage gap.
So, now what?
One thing that is mostly certain: we cannot rely on the current White House administration to treat the coverage gap with the urgency that is warrants. President Trump’s campaign promise to make healthcare costs more manageable for those barely able to stay financially afloat turned out to be little more than just hot air. In the draft of the American Healthcare Act, the poor and old were going to take the hardest beating.
But oh ye of little faith: do not fold up your tent and fall into despair, because Medicaid expansion is negotiated at the state level. It is time that we exert pressure on our government officials to fix this debacle before it worsens and, well, perhaps even explodes. (Note: explodes, not implodes) (Note: It will not actually explode, but this is a very pressing matter and I will take the liberty to use hyperbole here if it will startle you awake from a deep and blissful slumber and make you take heed.)
If states were fruits instead, Texas and Florida would be the low-hanging ones: they haven’t yet expanded Medicaid, but their populations have the most to gain if they did. To get the biggest bang for our bucks, it is wisest to concentrate our efforts there. The residents in these southern states need to urge their legislators to reconsider Medicaid expansion. After all, the nature of our electoral process means that legislators must be responsive to the demands of their constituents to stay in office, at least in theory.
If residents in Texas and Florida begin to utilize channels of civic engagement, by giving their representatives a ring and voicing concerns at town hall meetings, their public officials will hopefully come to their senses and recognize that they can no longer ignore the coverage gap.
Health policy is complicated, I get it. But because the stakes are so high in healthcare, it shouldn’t be a messy partisan issue that makes progress sluggish at best and paralyzed at worst.
Whether our allegiances are to the red or the blue, or somewhere in-between, let us find common ground in recognizing just how unjustifiable it is that some people in the U.S. of A. have been deemed too poor to qualify for government assistance, and then take strides to nip the coverage gap in the bud straightaway.
Explaining health care reform: questions about health insurance subsidies. (2016, November 1). Retrieved from The Henry J. Kaiser Family Foundation: http://kff.org/health-reform/issue-brief/explaining-health-care-reform-questions-about-health/
Garfield, R., & Damico, A. (2016, October 19). The coverage gap: uninsured poor adults in states that do not expand Medicaid. Retrieved from The Henry J. Kaiser Family Foundation: http://kff.org/uninsured/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/