During implementation of the Affordable Care Act, states were pressured into increasing Medicaid coverage to higher incomes. Many did not want to do it, not because they were against health care but did not want a flawed program consuming even more of state budgets.
The federal government gives states a 100 percent subsidy - but only temporarily. Due to unwillingness by the government to negotiate a fix for Medicaid, 24 states have decided not to be burdened with the higher costs and worry that Medicaid, designed for the poorest and sickest, will be forcing those patients to compete with healthy 25-year-olds for appointments. Estimates were that up to 60 percent of new Medicaid patients would be people who drop private health insurance.
As a result of the impasse, an estimated 1.1 million community health center patients won't be covered under the expansion, according to a paper by George Washington University scholars which also finds that the vast majority (71 percent) of the 1.1 million patients who will be left without coverage live in 11 southern states (AL, FL, GA, LA, MS, NC, OK, SC, TN, TX, VA).
"These low-income patients, many of them living in the South, already face significant challenges to obtaining health care," says lead author Peter Shin, PhD, MPH, director of the Geiger Gibson Program in Community Health Policy and an associate professor of health policy at Milken Institute SPH. "Our analysis suggests these patients will remain without access to affordable insurance, which will almost certainly lead to delays in care and the risk of more serious health conditions."
Unless the ACA covers them, regardless of whether or not the federal government can force states to do so.
In 2012, community health centers served 20.7 million patients in 8,000 medically underserved communities throughout the United States. Community health center patients tend to be uninsured or underinsured and they are typically much poorer than uninsured patients generally.
Shin and his colleagues estimate that the ACA would have helped 5.2 million out of a total of 7.5 million uninsured community health center patients to gain health coverage either by buying affordable policies or qualifying for Medicaid under the expansion programs. However, 1.1 million of the 5.2 million who could have gained coverage will remain uninsured due to states' decisions to opt out of the Medicaid expansion.
This report also shows that of the 1.1 million community health center patients left without insurance, 35 percent live in just five opt-out states (AL, FL, GA, LA, MS).
"Health center patients living in the South remain disproportionately affected by the failure to expand Medicaid," says Sara Rosenbaum, JD, the Harold and Jane Hirsh Professor of Health Law and Policy at Milken Institute SPH. "Of the community health center patients denied coverage by virtue of their zip code, most live in the south and more than one third lives in the Deep South." Poor, minority patients in these states already face troubling disparities in health and health care.
The decision to reject the Medicaid expansion threatens to make those disparities even worse, the advocates say, without recognizing that the blame for that failure is shared.
The analysis also shows that health centers in the opt-out states will likely forgo over half a billion dollars ($569 million) in revenues they would have received under a Medicaid expansion and that states said they could not afford. Money not gained is not money lost, though.
Community health centers in states that have expanded Medicaid face a very different future with up to 2.9 million uninsured patients in the expansion states gaining health coverage in 2014, according to the researchers, without counting how many of those dropped private insurance. The increase in insurance payments for everyone else could generate potential revenues of $2.1 billion in 2014, which help to pay for physicians, nurses, care for patients—and to further expand into isolated communities without access to crucial health care services. Unless even more people drop out of private insurance.