Living Poor and Uninsured in a Red State

Obamacare assumed states would expand Medicaid, but half of them aren’t. What will happen to those states' uninsured people?
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A woman stands at the registration window at a clinic in San Juan, Texas. (Eric Gay/AP)

When Claudia, a mother of seven who lives in a Dallas suburb, feels sick, she doesn’t bother trying to make a doctor’s appointment. Without health insurance, even a simple consultation would cost more than a day’s pay.

“I just take something over the counter or wait till I can't take it anymore,” she told me.

One such time occurred in 2002, when she had a complication after a gallbladder surgery.

“I was home for six days when I started to be in pain again,” she said. “I had just been in the hospital, so I was holding it off because I was worried that they'd send me another thousand-dollar bill.”

After several days of laying on the couch in agony, she gave up hoping that it would go away on its own. “I went to my husband crying, saying it was too painful. He agreed to take me,” she said.

Back at the hospital, doctors said the initial operation had punctured one of her bile ducts, and the bitter fluid was now leaking into her body. “The doctor told me that if I had waited longer, I would have been dead,” she said.

Claudia works in a warehouse for up to 11 hours a day, and though she’s occasionally wracked by aches and pains, she hasn’t gotten a physical in four years. Her children are healthy, but she admits that no one in the family has been to the dentist in a while. Her 19-year-old daughter pays for her own contact lenses with earnings from her job at McDonalds: Two paychecks for every optometrist visit.

Any money that otherwise might be spent on a costly out-of-pocket appointment is saved up instead for yearly trips to El Salvador, where Claudia’s husband moved with four of their children after he was deported eight years ago. Claudia has been managing like this since 2007, the last time she had a permanent job that provided health insurance.

When Claudia first learned about the Affordable Care Act, she was hopeful that the law would portend what its name implies.

But a few months ago, she arrived at a community meeting at the Irving public library to find that because she makes less than the federal poverty level, she does not qualify for the federal government’s subsidies to buy insurance. (The subsidies to buy insurance on the newly created exchanges only go to people who make 100 percent of the federal poverty level or more.) Without the subsidy, the family’s premium for a mid-level “silver” health plan on the exchange would be roughly $5,000 per year.

If she lived in, say, California or Kentucky, Claudia could simply enroll in Medicaid. The Affordable Care Act provided for states to expand the program to include low-income adults — a demographic that in most states has been traditionally ineligible for Medicaid, which was designed for children and pregnant women.

But in its June 2012 Obamacare decision, the Supreme Court ruled that states aren’t obligated to expand Medicaid, and Texas is currently one of the 25 states that have chosen not to expand the program. In April, Texas Governor Rick Perry, a Republican, called Medicaid expansion “a misguided, and ultimately doomed, attempt to mask the shortcomings of Obamacare” and has resolutely refused to consider it.

“I found out that Rick Perry had denied Medicaid,” Claudia said. “And I thought, ‘What's going to happen with me now?’”

It’s a question many Texans are asking themselves as vague newscasts about coverage deadlines and website fixes have stirred increasing numbers to learn more about Obamacare—with some finding bad news about their own prospects under the law. Texas has the highest rate of uninsured people in the nation, at 25 percent. In all, 1,046,000 people will fall into the state’s so-called “Medicaid gap”: the expanse between the minimum salary necessary to qualify for a federal subsidy to purchase insurance on the new Marketplace, or about $11,500 a year, and the maximum wage to qualify for Medicaid, which in Texas is about $3,500 for a family of four. At a time when millions across the country are gaining health insurance, it’s estimated that Texas’ Medicaid gap will swallow up 91 percent of the poor, uninsured adults in the state.

Kaiser Family Foundation

Of all the people who fall into this coverage gap nationwide, more than a fifth reside in Texas — in part because it, like many other southern states, also happens to have super-stringent Medicaid requirements. Able-bodied adults under the age of 65 without children don’t qualify for the program at all unless they are pregnant.

At free clinics and enrollment events in Dallas, “I don’t make enough to qualify for the subsidy” was a common ironic refrain, though most people I spoke with seemed to accept it as just another bureaucratic quirk.

“I thought with Obamacare I’d get better quality and services,” one woman told me. “I guess I don’t qualify.”

Not everyone faced the state’s decision with resignation, though. Rachel Pearson, an MD/PhD student at the University of Texas Medical Branch, sees low-income patients at a free clinic in Galveston.

“It felt like a slap in the face,” she told me.

“As a medical student, you’re constantly confronted with the bodies and lives of working-class Texans. You are called upon to sit and listen to somebody’s story, and you look in their mouth and their teeth are messed up, and you listen to their heart and there’s a murmur, and you’re telling them there’s a treatment for this, but the state has decided they should not be able to get that treatment,” she said. “These people deserve the fruits of the accumulated thousands of years of effort that have gone into making modern medicine.”

Without Medicaid or another form of insurance, getting to see any kind of doctor can be a struggle. But in Texas and other states that don’t expand the program, arguably the biggest challenge for the uninsured is — and will continue to be — accessing specialty care.

Texas’ network of community and charity clinics are relatively capable of providing in-a-pinch primary care to most of the state’s uninsured. But those in the Medicaid gap have few reliable options when it comes to surgeries, cancer treatments, and other higher-level care. The kind of treatment, in other words, “that most folks will never need. But when you do need it, there's no substitute for it,” said Anne Dunkelberg, associate director of the Center for Public Policy Priorities, a left-leaning Austin think-tank.

A frequent argument against Medicaid expansion here is that too few specialists participate in the program because of its low physician reimbursement rate. But a look at the current healthcare safety net in Texas reveals that, for all its warts, Medicaid still appears to be a better option, in terms of health access, than the status quo. Medicaid may have trouble attracting enough participating specialists, but for uninsured Texans, getting seen by a specialist under the current system requires a near-miracle.

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Olga Khazan is a staff writer at The Atlantic, where she covers health.

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