Sep 3, 2013 - By Tony Pugh, McClatchy Washington BureauWASHINGTON _ One month after undergoing a partial hysterectomy in 2011 to remove a rare form of ovarian cancer, Erika Neal of St. Louis got a double dose of more bad news: Her salary as deputy director of a nonprofit museum was being cut and her job-based health coverage was being eliminated.
Without insurance, she went more than a year without tests that would tell her whether the cancer had reappeared. Neal continued to work, however, and now relies on an emergency state program to pay for the quarterly tests.
But when the program ends in December, she won't be able to afford the diagnostic tests because her salary has been cut by 75 percent since 2009. As an adult with no children, she's also ineligible for Medicaid, the state-federal health plan for the poor and disabled.
With no options for coverage, Neal rightly fears for her life next year.
"I'm always praying, but in 2014, my prayers will be ever more fervent," she said. "If the cancer comes back and it's not detected, it'll kill me. Most ovarian cancers, by the time you find out you have it, you just need to plan your funeral. So it's a blessing they have a test for it, but I can't get the tests if I don't have health insurance."
Neal could rest easier if she lived in one of the 23 states where Medicaid eligibility is being expanded for low-income parents and childless adults next year under the Affordable Care Act. Michigan appears close to expanding Medicaid eligibility.
But Missouri and 20 other Republican-led states aren't participating in the health care law's Medicaid expansion, fearing the cost would require state budget cuts in other areas. The remaining states are still debating the expansion.
That leaves Neal and 5.5 million others in those 21 states to fend for themselves in the "coverage gap," a bureaucratic twilight zone where people with poverty-level incomes don't qualify for Medicaid and can't get tax credits to help buy coverage on the new insurance marketplaces. Enrollment for them begins in October and they open in January.
With limited access to preventative care, many in the coverage gap with manageable chronic illnesses could end up seeking primary care services in hospital emergency rooms, where medical aid is costly and fleeting.
"If they fail to get an insurance card and don't have ongoing adequate coverage, that's how they're going to continue to get care, in the most expensive, least efficient, least helpful way that they can," said Ellen Kugler, executive director of the National Association of Urban Hospitals.
Gerald Friedman, a health care economist at the University of Massachusetts Amherst, summarized the options for those caught in the coverage gap.
"There's no way they can afford individual coverage at that income level, so they'll do what they do now, which is they go to the free care pools in the hospitals, they go to public health clinics, they borrow from friends, they go to free clinics," Friedman said, "and they just get sicker and sicker."
While the legislative, judicial and executive branches all had a hand in creating the coverage gap, it was not by design. It was an unintended consequence of the 2012 Supreme Court decision that upheld the Affordable Care Act.
The law was supposed to provide health insurance for most Americans next year by expanding Medicaid in all states to people earning up to 138 percent of the federal poverty level. That's about $15,900 for an individual in 2013, or nearly $32,500 for a family of four.
Tax credits would then go to other low- and middle-income people to help them buy coverage on the insurance marketplaces. If the Medicaid expansion was implemented in every state as originally planned, an estimated 22.3 million Americans likely would have gained coverage next year, according to the Urban Institute, a nonpartisan social and economic policy think tank.
But when the Supreme Court ruled that states could opt out of the expansion, Republican-led states took advantage. Rather than expand their Medicaid programs, most kept their programs as is _ open mainly to the poorest of the poor.
In 33 states, parents must now earn less than the federal poverty level _ $19,530 for a family of three _ to be eligible for Medicaid, according to the Kaiser Family Foundation, a nonpartisan health care research group. Eighteen of these states limit eligibility to parents in severe poverty, which is 50 percent of the federal poverty level or lower.
Some Republican lawmakers worry that President Barack Obama's plan to pay for the new Medicaid enrollees could change or go by the wayside, like other provisions of the health care law that have been waived or postponed by the Obama administration.
Neal, of Missouri, isn't buying that argument.
"In 28 years, the federal government has never missed a Medicaid payment to the state of Missouri, so the notion that the government won't pay its share? The historical record does not bear that out," Neal said.
In Georgia, state officials have said there aren't enough caregivers to handle an expanded Medicaid population.
But that's a false argument, said Cindy Zeldin, executive director of Georgians for a Healthy Future, a nonprofit group that advocates for access to affordable health care. She said that concerns about the cost and provider shortages would be mitigated by the boost in jobs and spending that the Medicaid expansion would create for the state economy.
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