The Affordable Care Act is already cutting health care costs, especially at hospitals that in the past provided charity care for uninsured, low-income patients. The reduction in charity care in states that have expanded their Medicaid programs with federal funds means the costs for this care are no longer being shifted to insured and self-paying patients, which makes health insurance more profitable for hospitals and insurers without increasing consumer costs.
But this drop in costs is happening only in the states in about half of the nation that have expanded their Medicaid programs. The other states — mostly in the South and the Plains — have been involved in political struggles that have blocked expansion of health insurance for their poor residents.
Expanding state-run Medicaid assistance programs has been called critical for the success of the new federal health care law. In states that haven’t expanded Medicaid, it is currently available to those who have incomes at or below the federal poverty line, which in 2014 is $11,670 for a single person and $27,910 for a family of four. In the states that have expanded their Medicaid programs, the eligibility level is 138%, or $16,104 for an unmarried person and $37,375 for a family of four.
The federal health law was written with this expansion in mind, and it offers most people with incomes ranging from 138% to 400% of the federal poverty level the opportunity to be eligible for federal subsidies as they purchase health care policies through the new health insurance exchanges.
These subsidies were to be paid for by decreases in Medicare reimbursements to hospitals and doctors. The U.S. Supreme Court decided that the federal government could not force states to expand their Medicaid programs, but the cuts in Medicare reimbursements did not change.
Unfortunately, the cutoff point for a subsidy was set at 138%, leaving those between 100% and 138% with no options in the states that didn’t expand their Medicaid programs. The resistance to Medicaid expansion is creating a poverty gap.
“It’s a crime,” Lisa Dubay, a senior fellow at the nonpartisan Urban Institute, said of the poverty gap. “These are the most vulnerable people in our society. They have no other access to health care. We have no way to take care of them and that just seems wrong.”
Aside from the ethical dilemma of not providing health care to low income people who don’t have the ability to purchase subsidized insurance, there is a significant financial cost for the states that aren’t expanding. This cost is being passed on to providers and insurers alike, and they are beginning to exert pressure on state governments to agree to the federally funded expansions.