MEDICAID & Mortality

A decade after the Affordable Care Act was supposed to provide health-care coverage to all Americans, some people still struggle to afford health insurance and to access medical care.

These are the people who fall into what's called the coverage gap. Many of them live in Florida, working low-paying jobs. Now, a decade's worth of data shows how much the health-care disparities caused by the coverage gap are costing the most vulnerable among us, renewing calls for the state to take action to close the coverage gap.

Why the coverage gap exists

The coverage gap refers to a lack of health insurance for people who can't get traditional Medicaid because of too much income or other qualification reasons, yet they also earn too little income to receive subsidies to purchase insurance on the ACA health insurance exchanges. This gap, which ironically penalizes some impoverished people for taking the low-paying jobs available to them, seems illogical given the goal of the ACA was to provide everyone with coverage.

The original legislation didn't contain the gap; it came into being as an inadvertent and unforeseen side effect of politics.

As signed into law, the ACA not only created the marketplace exchanges so people could purchase insurance individually, but it also expanded Medicaid coverage to people earning up to 138% of the federal poverty level, including childless adults. Lawmakers deemed covering more of the lowest-income people with Medicaid was the most efficient way to provide them with health care because the Medicaid system already existed and functioned. As the largest health insurer in the country, Medicaid was already set up to provide more services to low-wage earners than the lowest priced of the marketplace private policies would provide.

Medicaid costs are shared between the federal and state governments. The expanded Medicaid even came with the federal government picking up more of the tab than it does for traditional Medicaid — at 90% paid by federal money instead of the 62% share the feds pay for traditional Medicaid — and some categories of traditional Medicaid recipients qualified to be transferred into the 90% federal reimbursement level once Medicaid expanded.

"The higher reimbursement rate for loads of populations that the state pays for currently at a much higher rate, like prisoners and pregnant women, all of that would be a budget savings with expanded Medicaid because we often pay 100% out of the state budget for these different populations," said Holly Bullard, chief strategy and development officer of the Florida Policy Institute.

However, the ACA's authors didn't anticipate the 2012 Supreme Court ruling that would allow states to choose to opt out of expanding Medicaid coverage. When the ACA went into effect in 2014, about half of the states opted out, many of them in the South — including Florida under Gov. Rick Scott, who fought against efforts by the Florida Senate to pass Medicaid expansion.

In the decade that has passed, more states have chosen to close the coverage gap for their most-vulnerable residents.

"We know that Medicaid expansion is good for state economies," said Alison Yager, executive director of the Florida Health Justice Project. "There's not a single state of the 40 states that have expanded Medicaid, not a single one has changed their mind. No, the expansion of Medicaid is a great deal for states because it's largely paid for by the feds, and it does a tremendous amount to support state health economies. With additional revenue comes the possibility of hiring more healthcare workers and supporting local economies in that way. So, the ripple effects of accepting this deal are really expansive and robust, and state after state after state have found that to be the case."

Now, Florida remains one of only 10 holdouts that has not closed the coverage gap and taken up the offer of the increased federal cost sharing, earning it the dubious distinction of having the fourth-highest rate in the country of uninsured individuals — at 13% of its population. This compares to a 7.3% rate of uninsured individuals in expansion states.

Since no other solution has been provided as a substitute to cover people who qualify neither for traditional Medicaid nor for the health marketplace subsidies, low-income people have been left in the gap without health insurance. Income limits to qualify for Medicaid are based upon a percentage of the federal poverty level (FPL), which in 2023 is $14,580 for a single person and $24,860 for a household of three.

Income limits vary by state. In Florida, pregnant people and infants qualify for Medicaid at around 200% of FPL, with children's qualification sliding down to 138% of FPL by the time they're in school. Parents or other caretaking relatives of children only qualify if the household earns no more than 30% of FPL, so taking even a part-time job would likely disqualify the adults in the family from receiving Medicaid. And without a child, a pregnancy, a disability, or qualifying as a former foster child under age 26, working age adults don't qualify for Medicaid in Florida no matter how low their incomes are. Yet subsidies for purchasing health insurance on the ACA marketplace don't kick in until household income reaches at least 100% of FPL and are offered to households that earn up to 400% of FPL.

As a result, an estimated 415,000 Floridians fall into the coverage gap and lack health insurance entirely. By closing the coverage gap through Medicaid expansion, all adults ages 18-64 would become eligible, and these people would get health coverage. They are part of the roughly 2 million estimated to still fall into the coverage gap nationwide. An additional estimated 375,000 Floridians with low incomes of between 100% and 138% of FPL also would be eligible to shift from buying the lowest-priced, minimal-coverage subsidized private insurance on the ACA marketplace to receiving more robust health coverage through Medicaid.

According to a report from the Georgetown University Center for Children and Families, 52% of these people live in households where at least one person works full-time and an additional 20% in households that contain at least one part-time worker. Their employers either don't offer insurance or the coverage is unaffordable. The people in these employed households who don't work themselves are either the families' caregivers, are attending school or are too ill to work. Nearly half of adults working in Florida who lack health insurance are employed in hospitality, restaurants, retail, cleaning or construction.

"Having a goodly amount of workers in the economy now who are working without insurance, at a part-time job that doesn't offer insurance or a gig worker, that's what our economy looks like in Florida," said Bullard. "So, this would be good for the economy and dramatically reducing the uninsured rate."

After the end of a federal public health emergency stemming from the COVID-19 pandemic, enrollment in Florida's Medicaid program dropped by nearly 235,000 people in May, according to data posted online by the state Agency for Health Care Administration. Decreases in enrollment have long been expected, as the state was unable to remove people from Medicaid during the public health emergency. The result was that enrollment expanded dramatically. As an example, 3,764,038 people were enrolled in Medicaid in March 2020 as COVID-19 hit the state and grew to 5,778,536 in April 2023, the agency's numbers show. With the public-health emergency ending this spring, enrollment decreased to 5,543,890 in May and is expected to continue declining. In part, that is because some people stayed on Medicaid during the public-health emergency though they no longer met income-eligibility requirements.

Caught in the coverage gap

Floridian Laura Swiskoski embodies several of the statistics listed in the studies. She's an older adult, but she hasn't reached Medicare age yet. She has diabetes severely enough to require insulin, which means she needs an expensive medication daily just to stay alive, but she has a low income coupled with no health insurance. She was the homemaker in a household where her boyfriend of 39 years (who died last year) worked in restaurants, so they didn't have health insurance through work. This put them into the coverage gap because they didn't qualify for Medicaid but didn't earn enough to qualify for ACA subsidies.

But as a Charlotte County resident, Swiskoski is fortunate to live in a place with access to well-organized free healthcare. The Virginia B. Andes Volunteer Community Clinic provides not only primary and semi-urgent care, but it also offers preventive screenings, wellness education and houses an onsite pharmacy — all free for patients whose income is 200% or less of poverty level. In 2022, the clinic provided around 18,000 patient visits and filled around 20,000 prescriptions.

"I truly love Virginia B. Andes and everyone there," Swiskoski said. "If you're hurting, you go there, and you get good doctors. And you get in fairly quickly, unless they're really busy. They help me with my insulin and help me monitor it, make sure my blood sugar and A1C and everything's good. A lot of people can't afford their prescriptions. I don't know what people would do without Virginia B. Andes if they didn't have the Medicaid because insulin is expensive. And it's frightening to think if there wasn't a place to go get it — if you couldn't afford it, what are you going to do? You're diabetic — you need it."

Charlotte County is somewhat unusual — and fortunate — in that the clinic has also managed to recruit a strong network of specialists and hospitals as partners to donate care to its low-income patients that it refers for care beyond what the clinic offers onsite.

"We're the true safety net in Charlotte County for individuals who are uninsured and have nowhere else to go," said Suzanne Roberts, CEO of the Virginia B. Andes Volunteer Community Clinic. "They're so sick when they come to us. We see lots of cancers that we identify, and we work with our partners after that diagnosis. We find especially that service workers are not able to receive employer health insurance benefits. So, that's where we come in."

While the clinic removes one barrier to healthcare — the cost — another barrier that studies show frequently impede people with low incomes from accessing healthcare is transportation. The Andes Clinic counts Charlotte County Transit as a community partner that can provide free rides to its building in the medical district of Port Charlotte. But this fall, the clinic will overcome the transportation barrier in a new way — by taking medical services around the county aboard a mobile clinic bus. The Charlotte County Board of Commissioners approved Roberts' proposal for start-up funds, and in addition to being hosted in parking lots of different partners around the county five days a week, the mobile clinic will also be available to help the county's emergency management and health departments with disaster relief.

"We have a plethora of community partners," Roberts said. "This work is hard work, so you can't do this alone. You need like-minded, mission-minded individuals around to be able to give the care. Every life is important."

A decade later, the outcomes are in

Now that a decade has passed since about half the states chose to implement the ACA as designed and extended Medicaid coverage to more of their low-income residents, there are results to show for the unintentional experiment set up by the 2012 court ruling.

A 2020 national study published in the Journal of Health Economics found Medicaid expansion was associated with a 3.6% decrease in all causes of mortality among adults ages 20 to 64 in the four years following Medicaid expansion in the adopting states. Most of the decrease was due to fewer deaths from chronic causes that typically respond to the management afforded by consistent access to health care. Another study found that improved access to medications used to treat chronic conditions, as well as a reduction of improper medication self-rationing among patients, particularly impacted the death rate from these health conditions in the expansion states. And then there are the serious illnesses caught by screenings.

Palm Beach County is another place in Florida that is fortunate enough to have a robust network of specialist doctors and medical facilities willing to donate care through Project Access, a community outreach project of the nonprofit Palm Beach County Medical Society Services.

"We've been able to bring together resources on many levels, but truth be told, this is just a Band-Aid," said Dr. Brent Schillinger, past president of the Palm Beach County Medical Society and vice-chair of Florida Policy Institute. "While we've done incredibly good things for a certain number of people who've been able to take advantage of this, it's kind of pathetic that here in the wealthiest, most powerful country in the world that we have to have systems like this. Health care really should be a right."

One argument put forth against expanding Medicaid is that free or low-cost charity clinics as well as Federally Qualified Health Centers (FQHC), which offer income-based sliding fee scales to people without health insurance, already provide a health-care safety net to low-income people in the coverage gap. A 2020 study published in the medical journal Health Affairs specifically studied this debate by comparing health outcomes for older adults in expansion versus non-expansion states. In the two years of the study, the number who experienced a health decline was about 2% lower in expansion states, leading the researchers to conclude Medicaid expansion would improve health outcomes even for patients already receiving care at safety-net clinics. They cited the fact that the clinics are intended for primary care, whereas Medicaid provides access to specialty care for the approximately 25% of clinic visits that resulted in referrals. Medicaid also provides a transportation benefit that clinics typically cannot, which overcomes another reason that is frequently cited as a barrier to seeking medical care.

Schillinger volunteers with two FQHCs in his area. He said another challenge to obtaining care with these clinics is that there can be a lengthy waitlist for scheduling appointments.

Expansion may save taxpayers money

For those who have argued that simply giving health coverage away will discourage recipients from working, remember that the current traditional Medicaid qualifications in Florida make it nearly impossible for adults to work even a part-time job. Also recall that over 70% of households in the coverage gap have at least one worker in them. A study done in the expansion state of Ohio found that four out of five Medicaid beneficiaries who worked reported that the health coverage made it easier for them to continue working. A 2018 study in the American Journal of Public Health found Medicaid expansion provided people with disabilities an alternate path to health coverage that permitted them to hold jobs rather than going onto disability pay to qualify for the medical coverage they needed.

With any government program, there are always concerns about how much it will cost. Interestingly, despite the fact that closing the coverage gap will cost the state some cost-sharing money, the net outcome will actually save the state hundreds of millions of dollars. Here's why: Some existing traditional Medicaid programs that the state pays a 38% costshare for will drop to a 10% cost because they'll be eligible for additional federal money — and then other programs that are currently fully funded by the state will become eligible for federal money.

The Florida Policy Institute estimated that, if the coverage gap had been closed for fiscal year 2022-2023, the $442 million for Florida's 10% share of Medicaid expansion would have been offset by gaining federal money of an additional $266 million for traditional Medicaid programs, such as adults with disabilities and pregnancy coverage, as well as an additional $355 million for the currently state-funded programs, such as corrections facility health care and behavioral health, for a net gain of $179 million.

Then there also would be a gain of tax revenue on the additional activity of healthcare providers and hospitals, to the tune of another $19 million. And just because Florida's legislators have spurned the expansion money doesn't mean that Florida taxpayers haven't contributed money to the national budget for the expansion — without any of that money flowing back to the state.

"We talk about the dollars in Medicaid expansion, and we have turned our thumbs up at federal money that would have come to the state," Schillinger said. "It's just totally illogical why. It's just a political thing, and it's too bad that this has to become a partisan issue."

Another study, by The Commonwealth Fund, estimates that Medicaid expansion would save Florida $271 million in 2025. It also estimated that increased demand for health-care services spurred by more people having health coverage would create about 134,700 new jobs in Florida.

While these numbers are estimates, they are backed up by the experience of states that have already closed the coverage gap. Expansion saved Louisiana nearly $200 million in fiscal year 2017. Pennsylvania gained $53 million in sales taxes and 15,500 new health-care jobs the first year after expansion.

The state Legislature hasn't debated Medicaid expansion since turning it down at the inception of the program. So, a coalition of organizations is trying to take the issue straight to the voters as a ballot initiative. Recent polling found 76% of Floridians support Medicaid expansion, including 61% of Republicans. The ballot initiative might appear during the 2026 election. ¦