ACA or not, thousands suffer without Medicaid
By Melinda Harrell
Published in News on February 4, 2017 11:50 PM
Wayne County is not immune to the potential fallout if the Affordable Care Act is repealed and not replaced.
In some ways, health insurance coverage for the poor has fallen by the wayside on the county level from the beginning due to the state's refusal to expand Medicaid.
The ramifications of that decision are still very present in Wayne County today.
"If someone in Goldsboro makes $17,000 a year, they qualify for the ACA subsidy," said Dr. Jonathan Oberlander, chair of the department of social medicine and professor in the department of health policy and management at the University of North Carolina at Chapel Hill.
"If someone makes $35,000 a year, they can can get a subsidy. But if they make less than $7,000, they do not qualify for the subsidy."
Wayne County residents who make less than 100 percent of the federal poverty line -- that is $11,770 a year for one person in a household; $15,930 a year for two; $20,090 a year for three; and $24,250 a year for four in a household -- do not qualify for ACA subsidies.
Had it been expanded, Medicaid could have cushioned that coverage gap for the extremely poor or lower-income working people by offering coverage outside of its current criteria for qualification.
Currently, Medicaid does not cover non-elderly, non-disabled adults with no children no matter their income. It does offer coverage to families with incomes of up to 50 percent of the federal poverty line.
Today in Wayne County, 39,247 individuals receive Medicaid.
Sen. Louis Pate, Dist. 4-Rep., of Mount Olive, serves as the state Senate deputy pro tempore, and he sits on the joint legislative oversight committee of Medicaid and N.C. Health Choice.
Pate voted against Medicaid expansion and remains opposed to it.
"These are able-bodied recipients that are unmarried and do not have family," Pate said of the people who do not qualify for Medicaid.
"Plus, it takes those folks out of the job market. We feel like their health care would be suited if they had a job and had insurance through their jobs."
For single person working a minimum-wage job at $7.25 an hour for 40 hours a week would make an average of $13,920 a year, Pate is correct -- that would qualify them for an ACA subsidy.
However, workers who are underemployed in a minimum wage job, or who are unemployed and single, would likely not qualify for either a subsidy or Medicaid. That leaves them without adequate, affordable health insurance and therefore without affordable health care.
That matters in Wayne County, where a substantial amount of people are living on or below the poverty line.
The State of the County Health Report released in 2014 reported that 23 percent of Wayne County residents live in poverty, and nearly half of county residents are low-income, on average.
The report also found that more than 17 percent of Wayne County residents are without health insurance.
In the same assessment, two top social indicators that influence the overall health of the community are poverty and access to health care.
The assessment highlights the need to address poverty and access to health care, as well as crime, education, health literacy, mental health and health conditions, in making significant health improvements in Wayne County.
HOW DID WE GET HERE?
In 2013, under the Affordable Care Act, North Carolina was given the option to expand Medicaid, said Oberlander.
He said the ACA was originally written to provide subsidies for coverage for people who met a certain income requirement -- between 100 to 400 percent of the poverty level -- and when states expanded Medicaid, everyone else making below that income barrier would qualify for Medicaid.
However, the mandate requiring states to expand Medicaid was kicked back by the U.S. Supreme Court and deemed unconstitutional; therefore the Medicaid expansion caveat was then handed to the states as an option.
In 2014, North Carolina opted not to expand Medicaid, a decision which cost the state an estimated $2.7 billion in federal funding that year.
According to a report released by the Milken Institute School of Public Health at George Washington University in 2014, the estimated number of people in Wayne County who would have been eligible for Medicaid coverage had it been expanded was 6,896.
And in 2016, the report estimates that 4,597 people went without Medicaid coverage due to the failure to expand Medicaid.
Pate said the General Assembly initially voted to not expand Medicaid because of what the lawmakers saw as a potential state cost of the program. Pate said the number of people covered under Medicaid would have ballooned, and the state would have invariably had to pay more into the program.
Under the ACA provisions, however, the federal government would have provided for 100 percent of the funding for the Medicaid expansion for the first three years.
So in 2016, the state would have been required to kick in. North Carolina would have been asked to fund 5 percent of the expansion, while the federal government would have continued to foot 95 percent of the bill.
The state would have then been required to fund 10 percent of the expansion, with the federal government paying for 90 percent, by 2020.
Pate said it is hard to trust the federal government to deliver on its promise for funding.
"We didn't feel like it was good health policy at the time," Pate said of the vote.
Not expanding Medicaid has been a bone of contention among health care providers and policy experts.
Oberlander said there were no benefits to not expanding Medicaid.
"A lot of Republican states have done it," he said.
"It doesn't have anything to do with health policy, but rather politics. And Medicaid expansion got stuck in the middle of it."
THE FUTURE FOR WAYNE COUNTY:
Gov. Roy Cooper and the Republican-led General Assembly are embroiled in a lawsuit in which the governor has made a last-ditch attempt to expand Medicaid, while the General Assembly says he does not have the power to expand the program on his own.
Oberlander said the fate of Medicaid in the state is up to the courts, but the outlook for a unilateral acceptance of the expansion does not look promising.
"I don't know what chance he has now," Oberlander said.
"I doubt the Trump administration will not grant a waiver when the Republican-led legislature says that Cooper shouldn't be allowed to expand Medicaid."
With the repeal of the Affordable Care Act, health insurance coverage would remain in an uneasy limbo, even for people who are covered under their employers and on the ACA exchange.
"Without a replacement it would be chaos," Oberlander said.
"Individual insurance markets will unravel; lots of North Carolinians would lose insurance. It would produce an increased amount of volatility in the insurance market and a lot of North Carolinians will lose coverage. There is a lot of concern right now. It is not so easy to come up with one, but because there isn't a replacement doesn't mean there won't be."
In Congress, there are some suggestions of ACA replacement. They include the American Health Care Reform Act, the Obamacare Replacement Act and the Patient Freedom Act.
Specifically, the Patient Freedom Act puts health insurance coverage back in the hands of the state.
It repeals the federal, individual and employer mandates, and offers the states options for coverage.
One option is the reimplementation of the ACA, which allows the states to keep the ACA requirements and mandates, as well as the Medicaid expansion dollars.
The second option allows for the state to choose an alternative on its own and still keep the Medicaid expansion money.
And the third option allows the state to design a replacement without federal assistance.
Pate said if the ACA was repealed and replaced with something similar to the Patient Freedom Act, the expansion of Medicaid would still not be an option.
"I don't think we have an appetite for Medicaid expansion," Pate said.