Opinion: Commentary: Who Takes Care of Uninsured Poor?

Opinion: Commentary: Who Takes Care of Uninsured Poor?

Mary Kimm’s summary (see “Killing the Poor to Pay Millionaires,” Alexandria Gazette Packet, June 29, 2017) of the disaster likely to befall the nation’s poor and most vulnerable if a version of the U.S. Senate bill to repeal and replace the Affordable Care Act (otherwise known as Obamacare) becomes the law of the land is excellent. Of course, the exact number of people projected by CBO to lose their health insurance – 22 million by 2026 – is only an informed speculation. What isn’t speculation, however, but rather is grounded in years of research is her conclusion that the law “would lead to more sick people and thousands of preventable deaths every year.”

I hope her plea to engage the public in contacting their senators to derail the Senate proposed bill, or any similar legislation that may spring forth following their return from the July 4 recess, proves successful, but even if it does — and Obamacare manages to survive another repeal and replace onslaught — it would be incorrect to think that most if not all low-income residents of Virginia (and Alexandria) are covered by health insurance.

What is often overlooked and frequently misunderstood is that Obamacare includes two separate and distinct programs:

  • State-based Health Insurance exchanges were created to provide premium tax credits to low-income and lower middle class individuals and families to purchase a comprehensive health insurance plan in the individual/non-group marketplace. (Eligibility for the premium subsidies was limited to those with incomes between 100 to 400 percent of poverty — a range of about $12,000 to $48,000 for a single individual.)

  • Under Medicaid Expansion, each state that agrees to expand its program to include almost all uninsured adults with incomes up to 138 percent of poverty (about $16,000 for an individual or $27,000 for a family of three) receives enhanced federal reimbursement (100 percent for first 3 years, 90 percent thereafter) for the new eligibles.

Since 2014, the first year states had the option to expand their Medicaid program, 31 states and D.C. chose to do so. The Virginia General Assembly, however, has rejected expansion legislation for each of its last four sessions, effectively leaving approximately 400,000 low-income individuals (about 5,500 in Alexandria) without comprehensive health insurance through Medicaid. So, it is fair to say that in Virginia, and in 18 others states that have not accepted the Medicaid expansion option, only half of Obamacare was ever implemented.

Those most affected by the absence of Medicaid expansion in the Commonwealth are predominantly non-disabled, non-elderly (18-64 years) adults (who were never eligible for Medicaid before Obamacare was enacted) and parents of children with incomes slightly above 50 percent of poverty, disqualifying them from coverage under the traditional Medicaid program. Many of these individuals are among the “working poor,” ie. they are employed part-to-full time mostly by businesses that do not offer health benefits or, if offered, employees cannot afford the premiums.

Many may ask: Why does this matter? It matters greatly because research has consistently shown that without insurance the health of those who are poor tends to suffer greatly. Specifically, experience indicates that compared to the low-income insured population (i.e. those covered by Medicaid), the uninsured poor:

  • are far less likely to have a source of health care, i.e. a “medical home”;

  • receive fewer preventive screening tests;

  • have a higher likelihood of being diagnosed with late-stage cancers;

  • have lower five-year survival rates, and,

  • are far more likely to experience preventable hospitalizations.

Moreover, lack of coverage for the “working poor” will likely contribute to a less healthy workforce, reduced productivity and even restrained economic growth.

Thankfully, the city and many community, health and faith-based organizations united early on to bring attention as well as resources to the health care needs of at least the most vulnerable of those uninsured residents who were being shut out of the Medicaid program. Over the past two years, the city and community hosted two free community health fairs for the uninsured residents of Alexandria (with more than 700 uninsured attending) and raised more than $200,000 over the previous and current fiscal years to expand access to primary (preventive) health care services for those low-income uninsured who are without a routine source of care or a “medical home.”

It is my hope that the headlines will once again proclaim “Obamacare lives!” — for that will be truly great news for the hundreds of thousands of “near poor” and lower middle-class individuals throughout the Commonwealth (including a few thousand in Alexandria) who have qualified (or may still qualify) for federal subsidies and purchased a plan in the marketplace. However, Obamacare’s survival will still be meaningless for the approximately 5,500 Alexandrians (and about 400,000 throughout the Commonwealth) whose only path to health insurance, namely via Medicaid expansion, will likely continue to be blocked by the Virginia General Assembly.

More than four decades ago, H. Jack Geiger, M.D., an early pioneer in the community health movement in the U.S., wrote: “The poor are likelier to be sick. The sick are likelier to be poor. Without intervention, the poor will grow sicker and the sick will grow poorer. And that has troubling consequences for all of us.”

Sadly, those words are just as true today as they were over 40 years ago.