Health 'coverage gap' affecting WNC residents

Some residents not eligible for ACA subsidies, Medicaid

Oct. 26, 2013
Pat McCrory
McCrory / AP


ASHEVILLE — Jerry Moncus lost his health insurance when he lost his job in a layoff.

For him, passage of the Affordable Care Act brought hope for coverage while he worked toward a degree and retraining at Asheville-Buncombe Technical Community College.

At 60, re-entering the workforce takes time.

But like 319,000 people in North Carolina, according to an estimate by the Kaiser Family Foundation, Moncus falls into a “coverage gap” resulting from the state’s decision not to expand Medicaid.

Some were left uninsured and driven out of work by a down economy. Others could be childless, working adults who make too little to qualify for subsidies through Obamacare, while at the same time falling into a category without access to Medicaid coverage.

“Of course, I’m very disappointed I’m not able to access the Affordable Care Act in any way,” Moncus said. “To me, the point was we cover our citizens with health care, and that’s not happening.”

With the launch of the Health Insurance Marketplace on Oct. 1, some of those in the coverage gap are finding out now that they don’t qualify for help.

Jan Plummer, N.C. navigator program coordinator at Mountain Projects, has been helping people in Western North Carolina review health care options through the federal marketplace.

Plummer says she’s encountered some residents who don’t qualify for help.

Some are frustrated, telling Plummer, “We thought this was gonna help us.”

They didn’t realize that North Carolina lawmakers had decided earlier this year not to expand Medicaid, she said.

“They are below 100 percent of the federal poverty level or they have no income whatsoever,” Plummer said.

Moncus and some classmates from A-B Tech have started a company called Extra Bits Studios LLC to create mobile apps, and he hopes to get that going. But in the meantime, he hasn’t been able to afford insurance on his own.

Moncus is able to get care at Western North Carolina Community Health Services.

But he has a friend who is uninsured who doesn’t have a health care provider.

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“He simply can’t afford it (to go to the doctor),” Moncus said.

Moncus said his friend also won’t qualify for help through the federal marketplace.

Robin Rudowitz, analyst with the Kaiser Family Foundation, a nonprofit focused on health care policy, said those uninsured people in the coverage gap will continue to have limited options to access health care.

“I think basically the people who fall into the gap are individuals who right now don’t have insurance and generally would continue to face the consequences of being uninsured,” Rudowitz said.

Medicaid debate

Currently, Medicaid in North Carolina only covers certain categories of low-income people including pregnant women below a certain income level, children of low-income families, parents of children younger than 18 if their income is less than half of the federal poverty rate and the elderly and disabled.

It does not provide coverage to childless adults unless they are disabled.

The Affordable Care Act included a provision to cover anyone below 138 percent of the federal poverty level by expanding Medicaid.

The federal government would pay 100 percent of the cost to expand Medicaid to those newly eligible Medicaid recipients for the first three years of expansion.

But the U.S. Supreme Court ruling allowed states to opt out of Medicaid expansion, and North Carolina lawmakers did just that.

For those who fall below 100 percent of the federal poverty level, the Affordable Care Act specifically prevents them from getting subsidies that will be available to other low income and moderate income people buying insurance on the Health Insurance Marketplace.

“I think the law as written did not anticipate this situation that really came about from the Supreme Court decision,” Rudowitz said.

Nationwide, the Kaiser Family Foundation estimates around 4.8 million poor, uninsured non-elderly adults will fall into the gap in those states not expanding Medicaid.

As of now, North Carolina is among 25 states that have said they don’t plan to expand Medicaid, according to the foundation. But that number has been changing.

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Ohio recently became the latest state to move toward Medicaid expansion.

Most states opting not to expand Medicaid are in the south and west. A large percentage of those who will fall into the coverage gap are in Texas, where more than 1 million people won’t have access to either Medicaid or health care subsidies.

In North Carolina, Gov. Pat McCrory’s recent comments to the Heritage Foundation in Washington raised the idea that North Carolina could be forced to expand Medicaid.

But a McCrory spokesman said the governor was referring to the Medicaid budget and a rule change regarding hospitals determining presumptive eligibility for Medicaid.

The rule change expands who hospitals can make eligibility determinations about before confirming they are eligible for Medicaid, said Ryan Tronovitch, deputy communications director for the governor.

“If the hospital is incorrect in its eligibility determination, the state can’t recoup the money spent during the presumptive eligibility period,” Tronovitch said.

Earlier this year, McCrory signed legislation rejecting Medicaid expansion. He and other Republican lawmakers have cited their concerns about the costs and problems with the existing Medicaid program.

McCrory has called the Medicaid system “broken.”

And Tronovitch said the governor’s stance on Medicaid expansion hasn’t changed.

“Before the state can consider expanding Medicaid, we must first reform the system to improve the quality of care while controlling costs,” he said.

Expansion push

Some of those who oppose the state’s decision say the governor’s criticism of the program has been unfair.

Gerrick Brenner, executive director of the group Progress North Carolina, cited a recent published report that said the state Department of Health and Human Services made edits to its response to a state audit. The changes made the Medicaid program look worse off than it is, the report said.

“There is just no good reason not to expand Medicaid,” Brenner said.

Brenner’s group launched a petition drive seeking a special legislative session to reverse course on Medicaid.

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The North Carolina Hospital Association also continues to talk to state lawmakers.

“We continue to tell them why we favor expansion,” said Don Dalton, vice president of public relations for the association.

Dalton said it is “impossible” to gauge if the discussions are having an impact.

“We would certainly hope that legislators and the governor are taking a continuing look at Medicaid expansion and realize the benefit it could be, particularly for poor North Carolina patients,” Dalton said.

Expansion of Medicaid would have covered an additional 500,000 people in North Carolina.

As federal reimbursements decline, hospitals in the state will continue to care for the uninsured.

“It’s sort of like a double whammy for some of the hospitals in the states that aren’t moving forward (with Medicaid expansion),” Rudowitz said.

Sen. Martin Nesbitt, D-Buncombe, said Democrats plan to continue to push for Medicaid expansion. “This one is an absolute no-brainer,” he said.

The state’s failure to expand Medicaid could mean higher insurance premiums for those who do have insurance in the state, he said.

“All of those that have insurance are gonna have to continue to pay for those who don’t,” Nesbitt said.

Rudowitz said there’s no deadline for states to decide on Medicaid expansion.

However, the federal government will only pay 100 percent of the expansion cost through 2016. After that, the share paid by the federal government will gradually decrease to 90 percent of the cost in fiscal year 2020.

Rep. Nathan Ramsey, R-Buncombe, said he won’t support Medicaid expansion until the Department of Health and Human Services and the governor “say they are ready for expansion.”

“When they believe they can execute the expansion and do it in a responsible way, I would vote for expansion,” Ramsey said.

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