By Emily Unger

A few months ago, I was having Shabbat lunch at a friend’s house, and the topic of health reform came up.  Some of the other guests were opposed to the Affordable Care Act, arguing that costs would go down more in a competitive, free-market system.  As I defended the expansion of health insurance, one of the guests who had been arguing against it stopped me.  “Maybe it’s just my ignorance,” he said, “but why aren’t all these low-income uninsured people covered under Medicaid already?”

Many people know of Medicaid as a health insurance program for the poor, but few people realize just how poor you had to be, before the Affordable Care Act, to qualify.  In New York State, a single, childless adult had to make less than $750 per month in order to qualify for Medicaid — just 78% of the federal poverty line, and rarely enough to even pay rent in New York City.  Elderly and disabled people, and parents of minor children, were permitted a slightly higher income, but still well below the poverty line.

Yet in the rest of the country, the state of affairs was even worse.  Nationwide, the average Medicaid eligibility level was an unbelievably low 47% of the federal poverty line — for those who were even eligible to be covered at all.  In many states, only parents, children, and elderly or disabled people were permitted to enroll in Medicaid, meaning that childless adults could have no income, live in abject poverty, and still not be eligible for public health insurance.

The Affordable Care Act revolutionized health insurance in America by putting into practice the not-so-radical idea that everyone, regardless of income or family status, should have access to health care.  While most media attention has focused on the insurance exchanges and new regulations placed on the insurance industry, the changes to Medicaid have largely slipped under the radar.  Yet, for low-income Americans, the Medicaid expansion under the Affordable Care Act is life-changing. While before, even those well below the federal poverty line might not have been eligible for Medicaid, now anyone up to 138% of the federal poverty line who isn’t already covered by Medicare should be eligible for Medicaid.

The operative word, of course, is “should.”  For although the Affordable Care Act raises the Medicaid eligibility level to 138% of the federal poverty line, the Supreme Court ruled that states have the option to ignore this part of the law and keep their Medicaid programs at the pre-ACA levels.  So far, 25 states are choosing to do exactly that.  Although these state governments, generally led by Republicans, claim budgetary concerns for not expanding Medicaid coverage, the federal government would actually pay the entire cost of the expansion for the first three years, and 90% of the cost after that.  In reality, the state governments that are refusing to expand Medicaid are doing so out of a desire to stop the Affordable Care Act at every turn, no matter how much its programs might benefit the state’s residents.

These states’ refusal to expand their Medicaid program will leave over eight million poor Americans without public health insurance.  Even more perversely, these people will not only be ineligible for Medicaid — they’ll also be ineligible to buy subsidized plans on the health insurance exchanges.  The Affordable Care Act makes no provision for government subsidies for people below 138% of the federal poverty line to buy insurance on the exchanges, because it was written with the expectation that those people would be covered by Medicaid.  Thus, for these people living under or barely over the federal poverty line, the only option available to them will be full-price private health insurance — insurance that could easily cost more than their entire monthly income.  This means that millions of people will continue to have no health care coverage of any kind.

These numbers — percentages of the federal poverty line, millions of people — may sound abstract.  Yet every day in my job, I see that when clients can barely pay for rent, food, and utilities, basic health care becomes an unaffordable luxury.  These clients often have backlogs of unpaid medical bills worth many times their monthly income, or need surgery but can’t pay for it, or haven’t seen a dentist in years.  For them, Medicaid is often their only salvation — the only way they can see their doctor, the only thing standing between them and mountains of debt.

Being forced to decide between food, rent, and health care has a real impact.  Before the Affordable Care Act, according to a Harvard Medical School study, about 45,000 people died every year due to a lack of health insurance coverage.  This coming year, as over 3.3 million people have already signed up for private insurance on the exchanges and over 6.3 million people have been determined newly eligible for Medicaid, many of these tragic deaths will hopefully be prevented.  Luckily for my clients, they live in a state where they can rely on having health care, even if they are struggling to make ends meet.  Yet in half the states in our country, some of these most vulnerable people will still be left behind.

Emily Unger is a current AVODAH corps member in New York City.  She works as a paralegal in the Evelyn Frank Legal Resources Program at the New York Legal Assistance Group.