The poor uninsured people in Middle Georgia will not be getting any health insurance despite the Affordable Care Act because our state is not expanding Medicaid.
People who are really poor -- those whose family incomes are below the federal poverty level -- are not eligible for the subsidies. The subsidies are for people with incomes between 100 percent and 400 percent of the federal poverty level. People with incomes above 400 percent of the federal poverty level are supposed to buy insurance without subsidies. People whose incomes are below the poverty level were supposed to be covered by the Medicaid expansion, which our state has opted not to join. So the uninsured poor are left without any realistic options at this time.
This is really sad because it leaves many of the sick, poor people in our region at risk for death, disability and unnecessary bankruptcy. In addition, it needlessly continues to burden our financially strapped hospitals with uncompensated care, and it denies our regions economy of a much-needed boost from the jobs that would have been generated by the federal funds from the Medicaid expansion.
Medicaid is the government-funded health insurance program for people with low incomes. Many people erroneously think Medicaid covers all poor people. Not true. In Georgia, the Medicaid program currently covers parents with incomes less than 39 percent of the federal poverty level. Adults without children are currently not eligible.
Eligibility criteria for children and pregnant women are more lenient. The federal poverty level is currently an annual income of $11,490 for an individual or $19,529 for a family of three. That means that in Georgia, a family of three has to have an annual income of less than $7,589 for the adults in that family to qualify for Medicaid.
In the states that have opted into the Medicaid expansion, any families with incomes below 138 percent of the federal poverty level are eligible for Medicaid -- $15,856 for an individual and $26,971 for a family of three. Adults without children are eligible for Medicaid under the Affordable Care Act if they meet the income criteria.
The federal government will provide 100 percent of the funding for the Medicaid expansion for the first three years. After that, the federal funding will decrease gradually to 90 percent in 2020 and remain at 90 percent.
Given the fact that the federal government pays 100 percent for the Medicaid expansion for the first three years and after which the federal funding drops but it never goes below 90 percent, it would appear the Medicaid expansion is a great deal for the states. So far, 26 states and the District of Columbia have agreed to the Medicaid expansion. Three states are actively exploring Medicaid expansion, and 21 states, including Georgia, have opted out of Medicaid expansion.
The Medicaid expansion gap exists because the poor, uninsured people (with incomes less than 100 percent of FPL) in these non-expanding states have no realistic options for obtaining health insurance. They do not qualify for Medicaid in their states, and they do not make enough money to qualify for subsidies under the Affordable Care Act. Most of the people who fall into the Medicaid expansion gap are the working poor: cooks, cleaners, landscapers, cashiers and other hard-working Americans.
The majority of the people affected by the Medicaid expansion gap live in the South, mainly because the existing Medicaid eligibility criteria in these states are very stringent. The Kaiser Family Foundation published an issue brief on Oct. 23, 2013, that looked at the coverage gap in the non-expanding states.
Texas has the largest number of people affected with approximately 1.046 million falling in the gap. Florida has the second-largest number with 763,890, and Georgia has the third-largest with 409,350 people. (Expanding Medicaid to 138 percent of federal poverty level would enroll an additional 650,000 people; the number included in the gap is 409,350 since people between 100 percent and 138 percent of the federal poverty level are eligible for subsidies.)
Access to care
Medicaid improves access to care, health status and financial security of its recipients. In a paper published in the New England Journal of Medicine on Sept. 13, 2013, Dr. Benjamin Sommers and his colleagues explored mortality and access to care among adults after states expand Medicaid. They concluded that Medicaid expansion led to a 6.1 percent relative reduction in all-cause mortality compared to nearby non-expanding states.
According to their analysis, 2,840 lives were saved for every 500,000 uninsured people who received Medicaid coverage. Based on an estimated 650,000 new enrollees, Medicaid expansion in Georgia would save 3,692 lives.
Hospitals, in particular, stand to benefit from Medicaid expansion. Presently, the uninsured go to the emergency room for their health care needs, and they cannot be turned away if they have a true emergency. Our hospitals in Macon are struggling financially because of the uncompensated care they provide to the poor, uninsured population. What people do not realize is that this has a major impact on the care received by the insured population as well.
The best way to understand the Affordable Care Act is to see it as a funding mechanism for EMTALA (Emergency Medical Trauma and Labor Act) that was passed by Congress in 1986 and signed into law by President Ronald Reagan. EMTALA is the law that prevents hospitals from turning away any patients with emergencies from their emergency room regardless of their ability to pay.
Can you imagine the uproar if EMTALA had been signed by President Obama? Talk about a Communist idea.
Unfortunately, EMTALA is essentially an unfunded mandate. As long as we have EMTALA, there cannot be a true free-market solution to health care, and I do not think anyone is really considering repealing the act. So without Medicaid expansion, we are still left with millions of uninsured people accessing the health care system at the most expensive and least effective point: the emergency room.
According to the Macon Economic Development Commission, the top employer in Macon is The Medical Center of Central Georgia, which employs 6,200 people. Coliseum Health System with 1,400 employees is the fourth-largest. Both the Medical Center and Coliseum have had to lay off employees because of financial challenges. The situation is particularly dire for the Medical Center that bears the major burden of indigent care in the community.
Kasich makes his case
Gov. John Kasich, a Republican from Ohio, has become the unlikely hero of Medicaid expansion. In his article Supersizing Medicaid, 2.0 which was published in The Telegraph on Nov. 17, 2013, David Oedel reported that Kasichs logic for expanding Medicaid was to reclaim our share of federal taxes to support jobs here in Ohio -- jobs that will be created in other states with our money if Ohio does not extend coverage.
He did say that, but he said a lot more. Kasich made the case that it was a moral imperative for him as a Christian to support Medicaid expansion. He was reported to have said that St. Peter was not going to ask him what he did to keep government small, but he was going to ask him what he did to help the poor. He may have been talking about the part of the Bible where Jesus tells his disciples that whatever they did for the poor, the least among us, they did for him (Matthew 25:35-44).
He went further in an article published in The New York Times on Oct. 28, 2013. He was reported as saying he was concerned about the fact that there seems to be a war on the poor, that if you are poor, somehow you are shiftless and lazy. And he asked the very people who complain to ask their grandparents if they worked at the WPA (Work Projects Administration), the New Deal agency that employed millions of previously unemployed people in public works projects from 1935 to 1943.
Taking care of our uninsured patients has always been challenging. It is stressful and depressing taking care of patients who you know are not going to do well despite your best efforts because of the financial barriers they face when they leave the hospital. We often get patients admitted through the emergency room or transferred from one of the outside hospitals with cardiac emergencies.
In the hospital they get the best treatment available. However, once they are discharged, they have nowhere to go for follow up if they are uninsured. They cannot afford their medications, and they certainly cannot afford rehabilitation. They usually do not do well.
That is why I support Medicaid expansion.
Dr. Obi Emerole is a cardiologist in private practice in Macon.