Millions still go without insurance if law passes

One of the biggest mis­con­cep­tions about Pres­i­dent Obama's health care over­haul isn't who the law will cover, but rather who it won't.

If it sur­vives Supreme court scrutiny, the land­mark over­haul will expand cov­er­age to about 30 mil­lion unin­sured peo­ple, accord­ing to gov­ern­ment fig­ures. But an esti­mated 26 mil­lion U.S. res­i­dents will remain with­out cov­er­age — a pop­u­la­tion that's roughly the size of Texas and includes ille­gal immi­grants and those who can't afford to pay out-of-pocket for health insurance.

"Many peo­ple think that this health care law is going to cover every­one, and it's not," says Nicole Lam­oureux, exec­u­tive direc­tor of the Alexan­dria, Va.-based National Asso­ci­a­tion of Free & Char­i­ta­ble Clin­ics, which rep­re­sents about 1,200 clin­ics nationally.

To be sure, it's esti­mated that the Afford­able Care Act would greatly increase the num­ber of insured Amer­i­cans. The law has a pro­vi­sion that requires most Amer­i­cans to be insured or face a tax penalty. It also calls for an expan­sion of Med­ic­aid, a government-funded pro­gram that cov­ers the health care costs of low-income and dis­abled Amer­i­cans. Addi­tion­ally, start­ing in 2014, there will be tax cred­its to help middle-class Amer­i­cans buy coverage.

The Supreme Court is expected to hand down a deci­sion this month on whether to uphold the law com­pletely or strike down parts or all of it. If it sur­vives, about 93 per­cent of all non-elderly, legal U.S. res­i­dents will be cov­ered by 2016. That's up from 82 per­cent this year.

Still, mil­lions of ille­gal immi­grants won't qual­ify for cov­er­age. This pop­u­la­tion will account for roughly 26 per­cent of those who will remain unin­sured, accord­ing to Urban Insti­tute, a non­par­ti­san think tank.

And many legal U.S. res­i­dents will go with­out insur­ance, too. About 36 per­cent of the pop­u­la­tion that remains unin­sured will qual­ify for Med­ic­aid but won't sign up for var­i­ous rea­sons. Oth­ers likely will make too much money to qual­ify for assis­tance but be unable to afford coverage.

Here's a look at some of the groups that will likely remain unin­sured if the law survives:

ILLE­GAL IMMIGRANTS

More than 11 mil­lion unau­tho­rized immi­grants live in the United States, accord­ing to the Pew His­panic Cen­ter, a non­par­ti­san research cen­ter. That amounts to nearly 4 per­cent of the total pop­u­la­tion. But there are no pro­vi­sions that address ille­gal immi­grants in the health care law.

They won't be able to sign up for Med­ic­aid. They won't be eli­gi­ble for the tax cred­its to help buy cov­er­age. And they won't be able to use online mar­ket­places that the gov­ern­ment will set up in order for peo­ple to get cov­er­age in a process that's sim­i­lar to buy­ing plane tick­ets on travel web sites. Those online exchanges, much like the tax cred­its, will require proof of citizenship.

"They will still need to find alter­na­tive ways to seek care because noth­ing in the law really expands cov­er­age and afford­able cov­er­age options for undoc­u­mented immi­grants," says Sonal Ambe­gaokar, a health pol­icy attor­ney with the National Immi­gra­tion Law Cen­ter in Los Angeles.

The topic is a polit­i­cally divi­sive issue. On one side, there are peo­ple who say that the gov­ern­ment should pro­vide health care for all U.S. res­i­dents — legal or not. The other side con­tends that doing so could take valu­able resources away from U.S. citizens.

"Because of the lim­ited sup­ply of health care, we're almost in a soci­o­log­i­cal triage," says Bob Dane, spokesman for the Fed­er­a­tion for Amer­i­can Immi­gra­tion Reform, a national group that calls for stricter immi­gra­tion laws. "It begs the ques­tion, 'Who do we serve, who do we serve first and who is not entitled?'"

Researchers have found that immi­grants tend to use the health care sys­tem less than legal res­i­dents. Ille­gal immi­grants, in par­tic­u­lar, tend to avoid using the health care sys­tem until they have to, favor­ing home reme­dies first or mak­ing cash pay­ments to providers when they need care. That pop­u­la­tion also is younger, so it gen­er­ally has fewer health care needs, says Tim­o­thy Waid­mann, a researcher with Urban Institute.

The think tank, using fed­eral gov­ern­ment sur­vey data, esti­mates that ille­gal immi­grants accounted for an esti­mated $18 bil­lion of the $1.4 tril­lion spent on health care in the United States in 2007. That adds up to less than 2 per­cent of total spending.

Some say exclud­ing ille­gal immi­grants from the over­haul will keep some legal res­i­dents unin­sured, too. Ambe­gaokar, the Los Ange­les attor­ney, points to par­ents who are ille­gal immi­grants but have chil­dren who are legal cit­i­zens because they were born in the United States.

If the par­ents are not eli­gi­ble, they may not know that their kids qual­ify. And in other instances, if one child is legal and the other is not, the par­ents may decide not to sign up either to avoid play­ing favorites.

"The goal is to enroll every­body who is eli­gi­ble," Ambe­gaokar says. "But when you make sys­tems com­pli­cated and require proof of ID, you're going to inevitably keep out peo­ple who should be in."

LOST IN TRANSLATION

Med­ic­aid, which cur­rently cov­ers more than 60 mil­lion peo­ple, is expected to add about 17 mil­lion more peo­ple to its pro­gram by 2016 if the law is upheld, accord­ing to the non­par­ti­san Con­gres­sional Bud­get Office, which researches bud­getary issues for Congress.

But peo­ple are still expected to fall through the cracks. That's because the require­ments and process for sign­ing up for Med­ic­aid can be con­fus­ing. And while the over­haul aims to make the process eas­ier, it won't smooth out all the wrinkles.

The prob­lem? Many peo­ple don't real­ize that they qual­ify for cov­er­age. And that likely will still be the case, albeit to a lesser extent, after Med­ic­aid expands.

Cov­er­age depends on how someone's income stacks up to fed­eral poverty guide­lines, which can be obscure to the aver­age per­son. Plus, because income can fluc­tu­ate, some­one could qual­ify one year but not the next.

"Regard­less of how much out­reach you do … you're never going to get per­fect enroll­ment," Matthew Buettgens, another Urban Insti­tute researcher, says.

Stay­ing enrolled can be another hur­dle. Med­ic­aid recip­i­ents have to re-enroll, some­times more than once a year. They can be dropped if they miss dead­lines, sub­mit incom­plete forms or if paper­work doesn't catch up with them after they move — some­thing poor fam­i­lies tend to do more fre­quently than the aver­age Amer­i­can household.

Leeanna Her­man learned this when an unex­pected $300 doc­tor bill arrived in the mail. The Bak­ers­field, Calif., res­i­dent was preg­nant and unem­ployed and didn't know her government-funded health cov­er­age had lapsed.

"I was freak­ing out," says Her­man, 23, who went a month with­out cov­er­age because she missed the dead­line to re-enroll. "How do you expect me to pay that?'"

Experts say online appli­ca­tions and elec­tronic ver­i­fi­ca­tion of income lev­els and other things will make this process eas­ier. But dead­lines will still mat­ter and some peo­ple don't have easy access to the Inter­net. And there will still be some peo­ple who sim­ply won't enroll.

"There will always be that seg­ment that says, 'Aw, the heck with it, I will just wait until I get sick and go to the ER,'" says Stephen Schilling, CEO of Clin­ica Sierra Vista, a non­profit that has a net­work of 27 com­mu­nity health cen­ters in California.

Schilling expects to still see a lot of unin­sured patients at the non­profit group's health cen­ters even if the law is upheld. The cen­ter sits in an agri­cul­tural area in California's San Joaquin Val­ley, pop­u­lated with migrant work­ers and sad­dled with an unem­ploy­ment rate of around 15 percent.

It cares for about 60,000 unin­sured peo­ple annu­ally, thanks in part to grants and a slid­ing fee scale for patients based on their fam­ily size and income. Schilling says he still expects between 20,000 and 40,000 unin­sured patients if the over­haul is implemented.

LIV­ING IN THE GAP

The over­haul calls for tax cred­its to help middle-class Amer­i­cans buy cov­er­age. But some peo­ple who make too much money to qual­ify for the tax cred­its may have a hard time find­ing an afford­able option for pri­vate health insurance

The sub­si­dies can pay a large chunk of the insur­ance bill. For instance, a 40-year-old per­son who makes $50,000 in 2014 and needs cov­er­age for a fam­ily of four might receive a gov­ern­ment tax credit of more than $8,000.

That would cover more than 70 per­cent of the pre­mium, or the cost of cov­er­age, accord­ing to a sub­sidy cal­cu­la­tor on the non­profit Kaiser Fam­ily Foundation's web­site. Of course, that esti­mate depends on the type of cov­er­age the per­son choses, where they live and whether they can get cov­er­age through work.

But the tax cred­its will go to peo­ple with incomes up to 400 per­cent of the fed­eral poverty level, or $44,680 for an indi­vid­ual this year. Peo­ple just above that level may have a hard time find­ing afford­able health insurance.

Angela Agnew Laws wor­ries that she might remain unin­sured like she has been for the past eight years even if the health care law is upheld.

Laws, who lives in Lees­burg, Va., runs a small busi­ness that cleans and main­tains com­mer­cial build­ings. She hopes her income will climb to about $60,000 by 2014, which would be too high for tax credit help.

A plan that offers more than just basic pro­tec­tion against big med­ical expenses could cost as much as $10,000 annu­ally for Laws. She could find less exten­sive cov­er­age for a lower pre­mium, but that may only save about $1,000.

Laws, 58, fig­ures that she'll remain unin­sured if she can't find an afford­able cov­er­age option that fits a monthly bud­get already crammed with pay­ments of $1,203 for rent $530 toward her car.

"It's a scary prospect for me," she says.

Posted by Scott Mahoney on Jun 19 2012. You can follow any responses to this entry through the RSS Feed. Both comments and pings are currently closed.