Kaiser estimates 318,710 North Carolinians fall in 'coverage gap'

By Karen Garloch - The Charlotte Observer, October 17, 2013

An estimated 318,710 low-income North Carolina residents will fall into a health insurance “coverage gap” and are likely to remain uninsured despite the federal health overhaul, according to a new analysis by the Kaiser Family Foundation.

It’s the latest estimate to be released as officials try to gauge the impact of the rollout of the federal Affordable Care Act.

This group includes people with incomes under the federal poverty level – $11,490 for a single person, $23,550 for a family of four – who would have been eligible for Medicaid if North Carolina officials had chosen to expand that government health program for the poor and disabled.

But North Carolina is one of 26 states – most with Republican governors and Republican-controlled legislatures – that rejected the expansion. The people who would have qualified for Medicaid are allowed to buy insurance through the online exchanges created by the new law, but their incomes are too low to qualify for premium subsidies.

That’s because the law called for those with incomes under the poverty level to be covered by the Medicaid expansion and provided for the federal government to pay the extra cost for the first three years and no less than 90 percent in later years.

But that arrangement fell apart last year after the U.S. Supreme Court ruled the law constitutional but said states could not be mandated to expand Medicaid.

The Kaiser estimate of people who fall in the gap is lower than the 500,000 figure that health officials and the news media have cited most often to describe the effects of North Carolina’s decision to reject the Medicaid expansion. That figure is based on information from the N.C. Institute of Medicine, provided by the state’s Division of Medical Assistance.

Pam Silberman, president of the IOM, said the state estimated that 630,000 low-income uninsured adults would have qualified for Medicaid because they have incomes of as much as 138 percent of the poverty level.

Some of them would have been disqualified because they’re illegal immigrants or legal immigrants who haven’t lived in the country long enough.

The state estimated that about 500,000 would enroll if the state expanded Medicaid, Silberman said. Of those, about one-third have incomes between 100 and 138 percent of the poverty level, and they would be eligible for premium subsidies.

But she said “the lion’s share,” about two-thirds, are under the under the poverty level and therefore not eligible for premium subsidies, either.

John Hood, president of the John Locke Foundation, has objected when others suggest that 500,000 people have incomes under the poverty level and would be ineligible for subsidies. He felt vindicated by the Kaiser report with its lower estimate, which is closer to Hood’s reading of the state’s data.

It matters, he said, because other economic estimates are based on those numbers and could affect federal funding and taxation.

Whether it’s 300,000 or 500,000, it’s still a lot, Hood acknowledged. “It is mostly a technical accuracy point I’m making,” he said. “There’s clearly a large population of people … who are left in the lurch.”

Adam Linker, a policy analyst with the N.C. Health Access Coalition, agreed.

“There are 500,000 people who would have gotten Medicaid expansion who won’t get it because we didn’t expand,” he said. “… At the end of the day, if you are basing your decision to expand Medicaid on whether there are 300,000 or 500,000 people left out, then your moral compass is broken.”

Rachel Garfield, senior researcher at Kaiser, said the “major point is that there are hundreds of thousands of people who are going to be ineligible (for Medicaid). A share of those people may be able to purchase coverage in the exchange (with premium subsidies). But that’s still going to leave the majority of them in that coverage gap.”

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