Miami's Sandra Pico is poor, but not poor enough.
She makes about $15,000 a year, supporting her daughter and unemployed husband. She thought she'd be able to get health insurance after the Supreme Court upheld President Barack Obama's health care law.
Then she heard that her own governor won't agree to the federal plan to extend Medicaid coverage to people like her in two years. So she expects to remain uninsured, struggling to pay for her blood pressure medicine.
"You fall through the cracks and there's nothing you can do about it," said the 52-year-old home health aide. "It makes me feel like garbage, like the American dream, my dream in my homeland is not being accomplished."
Many working parents like Pico are below the federal poverty line but don't qualify for Medicaid, a decades-old state-federal insurance program. That's especially true in states where conservative governors say they'll reject the Medicaid expansion under Obama's health law.
In South Carolina, a yearly income of $16,900 is too much for Medicaid for a family of three. In Florida, $11,000 a year is too much. In Mississippi, $8,200 a year is too much. In Louisiana and Texas, earning more than just $5,000 a year makes you ineligible for Medicaid.
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Governors in those five states have said they'll reject the Medicaid expansion underpinning Obama's health law after the Supreme Court's decision gave states that option. They favor small government and say they can't afford the added cost to their states even if it's delayed by several years. Some states estimate the expansion could ultimately cost them a billion dollars a year or more.
Many of the people affected by the decision are working parents who are poor — but not poor enough — to qualify for Medicaid.
Republican Mitt Romney's new running mate, conservative Wisconsin congressman Paul Ryan, has a budget plan that would turn Medicaid over to the states and sharply limit federal dollars. Romney hasn't specifically said where he stands on Ryan's idea, but has expressed broad support for his vice presidential pick's proposals.
Medicaid now covers an estimated 70 million Americans and would cover an estimated 7 million more in 2014 under the Obama health law's expansion. In contrast, Ryan's plan could mean 14 million to 27 million Americans would ultimately lose coverage, even beyond the effect of a repeal of the health law, according to an analysis by the nonpartisan Kaiser Family Foundation of Ryan's 2011 budget plan.
For now, most states don't cover childless adults, but all states cover some low-income parents. The income cutoff, however, varies widely from state to state.
Most states cover children in low-income families. Manuel and Sandra Pico's 15-year-old daughter is covered by Medicaid. But the suburban Miami couple can't afford private insurance for themselves and they make too much for Florida's Medicaid.
Manuel Pico, a carpenter, used to make more than $20,000 a year, but has struggled to find work in the last three years after the real estate market collapsed. He occasionally picks up day jobs or takes care of the neighbor's yard. Sandra Pico would like to work full time, but can't afford to pay someone to watch her 34-year-old sister, who has Down syndrome.
"No matter how hard I work, I'm not going to get anywhere," Sandra Pico said. "If you're not rich, you just don't have it."
In San Juan, Texas, 22-year-old Matthew Solis makes about $8,700 a year — too much to qualify for Medicaid in that state. Solis, a single father with joint custody of his 4-year-old daughter, said he works about 25 hours per week at a building supply store making minimum wage and is a full-time college student at the University of Texas-Pan American. He aspires to be a school counselor.
He recently sought medical care for food poisoning, visiting a federally funded clinic. But he doesn't see a doctor regularly because he can't afford private insurance. The new health law allows young adults to remain on their parents' insurance until age 26. But that doesn't help Solis, whose father is uninsured and whose mother died of leukemia when he was 8.
"I voted for him (Obama) because he promised we would have insurance," Solis said. "I'm pretty upset because I worked for Obama and I still don't have coverage."
His governor, Rick Perry, like Pico's governor, Rick Scott, is rejecting the Medicaid expansion. So Solis too is out of luck unless his circumstances dramatically change.
In all but one of the states where governors are rejecting or leaning against the expansion, the income level that disqualifies a parent from Medicaid is below the federal poverty line. Only in New Jersey, where Gov. Chris Christie has said he's leaning against the expansion, is Medicaid available to parents with incomes at the poverty line and slightly above. New Jersey will cover a parent making $24,645 in a family of three.
Most states base Medicaid eligibility for parents on household income and how it compares to the federal poverty level, which was $18,530 for a family of three in 2011, the year being used for easier state-by-state comparisons.
In Louisiana, the eligibility cutoff for a working parent is 25 percent of federal poverty, or $4,633 for a family of three. In Nevada, it's 87 percent of the federal poverty level, or $16,121 for a family of three.
That's been the range in states where governors are likely saying no to expanded Medicaid.
In contrast, states where governors have said they'll expand Medicaid are more generous with working parents. The Medicaid eligibility cutoff ranges in those states from Washington's $13,527 to Minnesota's $39,840.
To be sure, some states with generous coverage for parents have been forced to cut back. Illinois, facing a financial crisis, ended coverage last month for more than 25,000 working parents. Even so, the state still covers working parents with incomes slightly higher than the poverty line.
The national health law's Medicaid expansion would start covering all citizens in 2014 who make up to roughly $15,400 for an individual, $30,650 for a family of four.
The federal government will pay the full cost of the Medicaid expansion through 2016. After that, the states will pick up 5 percent of the cost through 2019, and 10 percent of the cost thereafter.
Why would a governor say no?
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These state leaders are in favor of smaller government. In principle, they don't want the federal government to expand — even if that expansion would help their own citizens. Also Medicaid is costly, taking a huge bite out of budgets already. And they don't want to be on the hook for paying any more of the tab even if it's years down the road.
"We don't need the federal government telling us what to do when it comes to meeting the needs of the citizens of our states," Florida Gov. Rick Scott wrote recently in an opinion piece for U.S. News and World Report. "And we don't need Washington putting states on the hook for future budget obligations."
Also, many conservatives view Medicaid as a wasteful, highly flawed program, akin to no health coverage. Many doctors across the country won't treat Medicaid patients because the payments they receive are so low.
When the Supreme Court ruled that states could opt out of the health law's Medicaid expansion, it raised the chances for inequity at a time when more Americans have fallen from the middle class into poverty, said Isabel Sawhill, a senior fellow at the Brookings Institution.
"Why should a sick person in Connecticut have access to health care when they don't in Mississippi and Texas?" Sawhill asked. "We really do have a very high level of poverty as a result of the recession. And the safety net is weaker than ever."
Medicaid, the nation's single largest insurer, is a state and federal program created in 1965 as a companion program to welfare cash assistance to single parents. Today, the elderly and disabled cost nearly 70 cents of every Medicaid dollar, not the stereotypical single mother and her children.
What's largely unknown to many Americans is who is left out of the safety net, said Cheryl Camillo, a senior researcher at Mathematica Policy Research. "A huge chunk of the populace is not covered, even by Medicaid," she said.
The political rhetoric during a presidential campaign focuses on the middle class and leaves the uninsured working poor largely invisible, said Rand Corp. researcher Dr. Art Kellermann.
"We hear a lot of talk about unemployment and the aspirations of middle-class Americans. But we don't hear about the consequences of unemployment and the consequences of the collapsing middle class," Kellermann said. Losing health insurance is one of those consequences.
"It's like the public just doesn't want to believe anything else until it hits home," he said, "Until it's their own child, brother or parent that got laid off when they were 58, until then, it's not real."
