WASHINGTON -- One month after undergoing a partial hysterectomy in 2011 to remove a rare form of ovarian cancer, Erika Neal of St. Louis got a double dose of more bad news: Her salary as deputy director of a nonprofit museum was being cut and her job-based health coverage was being eliminated.
Without insurance, she went more than a year without tests that would tell her whether the cancer had reappeared. Neal continued to work, however, and now relies on an emergency state program to pay for the quarterly tests.
But when the program ends in December, she wont be able to afford the diagnostic tests because her salary has been cut by 75 percent since 2009. As an adult with no children, shes also ineligible for Medicaid, the state-federal health plan for the poor and disabled.
With no options for coverage, Neal fears for her life next year.
If the cancer comes back and its not detected, itll kill me, she said. I cant get the tests if I dont have health insurance.
Neal is one of the estimated 5.5 million people living in 21 Republican-led states, including Florida, that are not participating in Obamacares Medicaid expansion, according to the Urban Institute, a nonpartisan social and economic policy think tank.
Instead, Neal and millions like her will fend for themselves in the healthcare coverage gap a bureaucratic twilight zone where people with poverty-level incomes dont qualify for Medicaid and cant get tax credits to help buy coverage on the new insurance marketplaces. Enrollment in those marketplace plans begins in October and is effective in January.
An estimated 995,000 Florida residents will fall into the coverage gap, according to the Urban Institute
In 24 states and Washington, D.C., Medicaid eligibility is being expanded to an additional 4.5 million low-income parents and childless adults next year under the Affordable Care Act. Another 1.5 million poor uninsured adults live in the states that are still undecided.
With limited access to preventative care, many in the coverage gap with manageable chronic illnesses could end up seeking those services in hospital emergency rooms, where medical care is costly and fleeting.
If they fail to get an insurance card and dont have ongoing adequate coverage, thats how theyre going to continue to get care, in the most expensive, least efficient, least helpful way that they can, said Ellen Kugler, executive director of the National Association of Urban Hospitals.
Jackson Health System, Miami-Dades public hospital network, serves more Medicaid patients than any other medical facility in Florida, and its emergency rooms are frequently the frontline healthcare delivery system for the countys estimated 740,000 uninsured, or roughly one of every three residents.
The safety-net hospital system serves tens of thousands of uninsured patients each year through the emergency room, stretching Jacksons financial resources dangerously thin.
Ed ODell, a Jackson spokesman, said the hospital system expects to take a financial hit next year because of federal healthcare reforms and the states transition to Medicaid managed care.
Under Medicaid expansion, he said, that impact could be lessened.Medicaid serves approximately 3.3 million people in Florida, with more than half of them 20 years old or younger. The estimated costs for providing Medicaid to Florida residents from July 2012 through June 2013 are approximately $21 billion.
In 2011 and 2012, care for Floridas Medicaid recipients cost $20.3 billion, with the federal government paying 56 percent, or $11.3 billion, and the state picking up 44 percent, or about $9 billion.
To qualify for Medicaid in Florida, adults younger than 65 must be disabled or earn 19 percent or less of the federal poverty level and have a dependent child.
According to the U.S. Census Bureau, Florida has the nations second-highest rate of uninsured residents younger than 65, an estimated 3.8 million people, or about 25 percent of the state population. Only Texas has a higher rate of uninsured.
While the legislative, judicial and executive branches all had a hand in creating the coverage gap, it was not by design. It was an unintended consequence of the 2012 Supreme Court decision that upheld the Affordable Care Act.
The law was supposed to provide health insurance for most Americans next year by expanding Medicaid in all states to people earning up to 138 percent of the federal poverty level. Thats about $15,900 for an individual in 2013, or nearly $32,500 for a family of four.
Tax credits would then go to other low- and middle-income people to help them buy coverage on the insurance marketplaces. If the Medicaid expansion was implemented in every state as originally planned, an estimated 22.3 million Americans likely would have gained coverage next year, according to the Urban Institute.
But when the Supreme Court ruled that states could opt out of the expansion, Republican-led states took the option. Rather than expand Medicaid programs, most kept their programs as is open mainly to the poorest of the poor.
In 33 states, parents must now earn less than the federal poverty level $19,530 for a family of three to be eligible for Medicaid, according to the Kaiser Family Foundation, a nonpartisan healthcare research group. Eighteen of these states limit eligibility to parents in severe poverty, which is 50 percent of the federal poverty level or lower.
Florida is one such state, with its estimated 995,000 residents in the coverage gap. For instance, a family of four with an annual household income between $4,721 and $23,300 or 20 to 90 percent of the Federal Poverty Level for 2013 would be on their own to find health insurance.
Some Republican lawmakers worry that President Barack Obamas plan to pay for the new Medicaid enrollees could change or go by the wayside, like other provisions of the healthcare law that have been waived or postponed by the Obama administration.
Neal, of Missouri, isnt buying that argument.
In 28 years, the federal government has never missed a Medicaid payment to the state of Missouri, so the notion that the government wont pay its share? The historical record does not bear that out, Neal said.
In Georgia, state officials have said there arent enough caregivers to handle an expanded Medicaid population.
But thats a false argument, said Cindy Zeldin, executive director of Georgians for a Healthy Future, a nonprofit group that advocates for access to affordable healthcare.
She said that concerns about the cost and provider shortages would be mitigated by the boost in jobs and spending that the Medicaid expansion would create for the state economy.
We are not bringing in new people from another state into Georgia, Zeldin said. Were talking about Georgians who are already here, who already have healthcare needs, who are already sporadically using the safety net or hospitals seeking care only when its too late.