How Low-Income Americans Live (and Whether They Live) Depends on Where They Live

TalkPoverty.org recently hosted an online panel discussion on policy solutions to the economic insecurity — and downright poverty — that the latest Census figures confirm.

Toward the end of the discussion, the moderator asked panelists for their views on the “political environment” for their solutions. None saw more than the remotest chance of positive action by Congress. All noted good things happening at state and local levels — and expressed hopes for more.

There’s a flip side to these good things. They aren’t happening everywhere. And they almost surely won’t. We have a sort of inequality that’s not much talked about — the markedly unequal opportunities and safety-net supports for low-income people, depending on where they live.

Nothing new about this, of course. I’m moved to remark on it by an analysis the Urban Institute published the same day as the panel discussion.

The Institute looks at what will happen to poor and near-poor uninsured adults in the 23 states that haven’t expanded their Medicaid programs, as the Affordable Care Act required, until the Supreme Court said it couldn’t.

As you may recall, the ACA had required states to provide Medicaid coverage to non-elderly adults with incomes no greater than 133% of the federal poverty line — effectively 138% because of the way income is calculated.

The law also allows anyone in the same age bracket to purchase health insurance on an exchange if they can’t get affordable health insurance through their employer, but only if their income was at least 100% of the FPL.

What this means is that an estimated 6.3 million people have fallen into a coverage gap, being ineligible for both unexpanded Medicaid and for affordable health insurance offered on an exchange.

Needless to say (I hope) very few adults so poor can get health insurance sponsored by their employers. And there’s no way they can afford to buy it at market rates.

Their median annual income is just $9,500 — 65% of the FPL, the Institute reports. But it’s considerably lower in a number of states — 61% of the FPL in three (all Southern) and 49% in Alaska, where the median annual income for left-out residents is $7,422.

And, of course, half of the adults in the coverage gap have incomes lower, which means trying to get by on no more than $800 a month in most of the non-expansion states.

Some of these states have also done their best to limit purchases on the exchange that the federal government set up because they wouldn’t create their own.

As I’m sure you’re well aware, the exchange website isn’t altogether user-friendly. Even if it were, assessing the different plans offered and deciding which to choose wouldn’t be easy, especially if you’ve never had health insurance before.

The ACA, however, provided funds for “navigators” to inform consumers and help them through the enrollment process. And the U.S. Department of Health and Human Services established requirements to make sure they could do the job, e.g., training on a range of topics, a certification exam.

At least 13 states piled additional requirements on, according to a Health Care America Now review. Texas, for example, doubled the training hour requirements and added background checks. Can’t have ex-felons advising people on health insurance, you know.

It also requires community groups to secure liability protection, e.g., an insurance policy, for the navigators they retain and to comply with a bunch of additional rules. More costs clearly intended to hamstring the groups’ activities.

Indiana and several other states did something similar through licensing requirements that reportedly cost as much as $175 per navigator. Florida barred navigators from its public health offices.

We can see the results in the latest American Community Survey figures. In Texas 22.1% of the population had no health insurance last year. In the District of Columbia and Hawaii, just 6.7% of residents didn’t. Only Massachusetts, whose own healthcare reform gave it a jumpstart, had a lower rate.

We see similar divides in other state-level policies that affect the lives of low-income people, e.g., minimum wage rates, welfare benefits. I single the ACA pushback out because it’s so egregiously political, perverse and consequential.

Political because the state governors and/or legislative majorities want the ACA to fail — and more importantly, to ensure they don’t get beaten in the next primaries by candidates even further to the right.

Perverse in part because expanding Medicaid wouldn’t cost the states one thin dime until 2016 and only 10% of the costs of health care for the newly-eligible from 2020 forward.

Some of these costs would be offset by savings on care for people without insurance, however. So the extra states would have to spend would be a miniscule percent of what they have to spend anyway — 0.3%, on average, another Urban Institute analysis found.

And some states, the Institute concluded, would probably come out ahead. Another of its studies estimated states’ total savings at $12 billion to $19 billion a year, beginning in 2020.

We don’t need number-crunching to know that states gain nothing by deterring their residents from purchasing health insurance on an exchange. If anything, they’re stiffing their hospitals, virtually all of which must provide emergency care, whether patients can pay for it or not.

But people without health insurance generally don’t get much else by way of medical care. No routine checkups to detect so-called silent health problems like diabetes and hypertension. No screenings that can detect certain types of cancers.

Nor do people without health insurance generally have the wherewithal to follow recommendations they may get, e.g., to take prescribed medications at prescribed intervals, to get followup tests.

There’s been a lot of back-and-forth among experts over how many people will die because their states haven’t expanded Medicaid. The truth is we don’t know (yet).

But it seems as clear as day that low-income people — and some not-so-low — can look forward to longer, healthier lives in some states and will die unnecessarily in others. And if that’s not inequality, then I don’t know what is.

 

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