Gap Leaves Thousands Without Health Insurance

April 28--President Obama earlier this month highlighted the 8-million-plus people who signed up for insurance through his signature health care law, saying that despite its computer flaws and political opposition, the first enrollment period was a success.

"This thing is working," he said.

But while government officials and Obamacare supporters take a victory lap, people like Lisa Meixsell can only watch and hope they don't get sick.

It's tough being unable to afford insurance while others in similar situations on the other side of the Pennsylvania border -- be it New Jersey, New York, Ohio, West Virginia, Maryland or Delaware -- receive coverage through expanded Medicaid, Meixsell said. Pennsylvania passed on the Affordable Care Act's Medicaid expansion plan, joining 23 other states. The state now has a plan to expand Medicaid, a program shared with the federal government, but the earliest it could be ready is 2015 -- if it is even approved.

"I'm angry that our governor and Pennsylvania Legislature have turned their backs on hardworking, low-wage Pennsylvanians," Meixsell said. "The notion of being on the outside looking in, because I happen to live in the wrong state, was a tough pill to swallow."

The Nazareth woman is like hundreds of thousands of Pennsylvanians who make too much money to meet Medicaid's financial limits but too little to qualify for a health insurance subsidy under the law. The authors of Obamacare assumed states would accept the federal government's offer to cover the entire cost of expanding their Medicaid programs -- sliding to 90 percent of the cost in 2018 -- and providing an insurance bridge to low-income working people. But the U.S. Supreme Court in 2012 made expanding Medicaid optional, and 24 states haven't done so.

That leaves Meixsell with no choice but to go without coverage.

Like many of the 280,000-plus Pennsylvanians who fall into the "coverage gap," Meixsell applied for subsidized coverage. Unlike most of them, she said she initially was approved for a subsidy, but when she went looking for the subsidy for her tax records, it wasn't there. Meixsell later found she hadn't qualified.

A part-time employee at National Penn Bank who is studying for a bachelor's degree, Meixsell made about $13,000 last year, which should have been enough to put her beyond the coverage gap.

She said an assister at the federal insurance marketplace call center told her she didn't know why Meixsell's application was rejected. Meixsell said she's been relying on free pharmaceuticals and her primary care doctor, who charges her a lower fee that she pays out of pocket.

People in Meixsell's position could get help if the federal government approves changes to Pennsylvania'sMedicaid program as outlined in Gov. Tom Corbett's Healthy PA plan. Under that plan, submitted in September, the state would cut benefits for some current Medicaid recipients, impose premiums and use the federal expansion funds on private plans.

Officials at the U.S. Department of Health and Human Services are in negotiations with the state over the plan.

The talks are proceeding too slowly for Corbett, who earlier this month said he was getting close to his "breaking point."

Advocates also are unhappy, saying that Medicaid expansion as the federal health law proposed would be easier and more efficient than Corbett's plan.

"Healthy PA is overly complex, overly complicated and unnecessary," said Antoinette Kraus, director of the Pennsylvania Health Access Network. "The best choice for Pennsylvania taxpayers and uninsured workers is to join all of our surrounding states by expanding Medicaid immediately."

Even if federal officials approve Healthy PA soon, coverage still wouldn't begin until 2015.

That means Meixsell will have to put up with a lingering issue with a disc in her neck. "I've just learned to live with it," she said.

Delaying care and charity have become a way of life for Carol Zawediuk, who cares for her elderly father in Allentown.

She said she last had health insurance in 2002, when she was covered by her ex-husband's post-employment coverage. Since then, she has sometimes gotten free or nominally priced care offered by Lehigh Valley Health Network and St. Luke's University Health Network.

"It's not insurance," she said, "but I have the availability of a doctor if I need one."

When she applied, Zawediuk said she had no viable option -- the cheapest unsubsidized plan was $391 a month, more than her income.

Zawediuk said her 401(k) plan from when she worked disqualifies her for Medicaid under Pennsylvania rules and at 58, she still has years to go before she becomes eligible for Medicare.

Like Meixsell, Zawediuk said she was angry and frustrated that she didn't qualify for subsidized coverage. Now, she is scared.

"What will happen to my family if I become seriously ill?" she asked. "That is what keeps me awake at night. I know the hospitals cannot refuse to treat me, but how would I pay the bills? Suppose my appendix ruptures. Suppose I fall down the steps and break a bone. What if I get cancer?"

To keep the worries from becoming overwhelming, Zawediuk said she focuses on living day to day, "as though everything is as normal as it is supposed to be."

That's the only choice for an estimated 4.8 million people across the country who live in states that did not expand Medicaid and are in the coverage gap, according to the nonpartisan Kaiser Family Foundation.

Karen Prokup of Bushkill, Pike County, is one of them. Although she works, Prokup doesn't have health insurance. She said her health is good, but her husband's isn't. He also is not covered.

"I thought the whole point to this mess was to get insurance for those of us who can't afford it," she said.

For now, the only way out is the path Meixsell is taking. She said she's gotten a promotion to full-time work at National Penn and will be eligible for benefits June 1.

"Although my personal situation has a happy ending, my experience with ACA was not a good one," Meixsell said. "And I worry about others who will lose out due to misunderstandings with the process or the income gap."

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Twitter: @timdarragh

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