Many people are talking today about this article in today's New York Times, which focuses on the particularly cruel doughnut hole created when the Supreme Court allowed states to opt out of the expansion of Medicaid in the Affordable Care Act. The problem is that if you live in a (mostly Southern) state run by Republicans, you have to be desperately poor to qualify for Medicaid under existing rules. But it isn't until you get to 133 percent of the poverty level ($31,321 in yearly income for a family of four) that you're eligible for subsidies to buy insurance on the exchanges, because when the law was written the idea was that everyone under that income would get Medicaid. When all those Southern states decided to refuse the Medicaid expansion in order to shake their fist at Barack Obama, they screwed over their own poor citizens. So millions of people will be caught in the middle: not poor enough to get Medicaid, but too poor to get subsidies on the exchanges. But when we say "not poor enough," what we're talking about is people who are, in fact, extremely poor. And you'll be shocked to learn that in those states, the poor are disproportionately black. Could that have anything to do with it? Heavens, no!
In any case, I thought it might be worthwhile to lay out in one handy chart how, state by state, this will affect people. Under pre-ACA law, each state sets its own eligibility level for Medicaid. In more liberal states, these levels are fairly high; for instance, Massachusetts gives Medicaid to families up to 133 percent of poverty, New York up to 150 percent, and Minnesota up to 215 percent. But in conservative states, the levels are far stingier; as someone in the Times article says, "You got to be almost dead before you can get Medicaid in Mississippi." In addition, in most states childless adults can't get Medicaid no matter how poor they are, but under the ACA it will no longer matter whether you have children. This is just one more way conservative states that forego the Medicaid expansion (for which the federal government is picking up almost the entire tab, by the way) are harming their own citizens.
On to our chart. One note: most states have different levels for working and non-working people; the levels are higher for those with jobs. I've used the figures for working families. The bars in red are the states that have rejected the Medicaid expansion, and as you can see, almost all of them are clustered at the lowest end of the eligibility spectrum. That means that the states where the Medicaid expansion would have done the most good for the most people are precisely those states where Republican governors and legislatures have told their poor citizens that they're out of luck.
When you look at these income eligibility levels, you see just how cruel the existing system is. For instance, in Alabama, you can't get Medicaid if your income exceeds 23 percent of the poverty level, or $4,500 for a family of three. Just think about that for a second. Do you think you could find a place to live, pay your bills, and feed your family on that income? But the state of Alabama says if you're that rich, you can afford to buy health insurance. In Texas, the state that will be depriving the most people of insurance by rejecting the expansion, only families under 25 percent of the poverty level, or $4,894 for a family of three, will be eligible for Medicaid. I'm guessing that's about what Rick Perry spends on boots every year.
It may be that in the next few years, many of those states will give in and accept the money, instead of making their poorest citizens the victims of their loathing for Barack Obama. Let's hope.