Gina Upchurch: Those left out of Medicaid

May 16, 2014 

In reading the May 9 article “ Hagan gives strong support of health law,” readers might have been confused about who is being denied access to health insurance coverage because North Carolina has not expanded Medicaid. The article stated, “They earn too much to qualify for health coverage under the Medicaid program, which serves the poor and disabled, but not enough to get federal subsidies to help purchase insurance on the state’s marketplace.”

While many individuals don’t qualify for our current Medicaid program because their incomes are too high – and states have different income requirements – the people left without health insurance options now have incomes that are plenty low; however, they are not the right “category” of person.

To be eligible for Medicaid in North Carolina, you not only have to have very limited income and assets, you also have to be one of the following: 65 or older, considered disabled by Social Security standards, blind, a pregnant woman, a child or in some rare cases in need of emergency care. The expanded Medicaid option simplifies eligibility because it doesn’t categorize people other than ensuring they are legal residents or citizens with very limited incomes.

The income limit used to qualify for expanded Medicaid would be 138 percent of the federal poverty level or roughly $33,000 for a family of four. The Affordable Care Act was written with the assumption that states would cover those below the poverty level (with 100 percent federal funds tapering to 90 percent over a handful of years). Thus, the federal subsidies to purchase insurance through the exchanges are available only for those above this income level.

The article also notes that individuals in the states that haven’t expanded Medicaid are in the “coverage gap.” This term is often used to describe the Medicare prescription “donut hole.”

This is misleading. Only a quarter of Medicare beneficiaries ever experience this “back end” gap, which occurs when beneficiaries and their plans have already spent $2,850 on covered medicines and ends when $6,455 has been spent. In fact, because of the ACA, Medicare beneficiaries who reach the gap now receive 52.5 percent discounts on brand-name and 28 percent discounts on generic medicines during the gap.

The so-called Medicaid coverage gap doesn’t come later in the benefit like Medicare D. It is a road block to our poorest citizens at the starting line. If you aren’t the right “category” of person, you simply don’t qualify for Medicaid in North Carolina no matter how poor you are.

One key point rarely mentioned is that expanded Medicaid does not have to include the same benefits as current Medicaid. This is critical because one of the main drivers of our state’s Medicaid budget is the ever-growing cost for long-term care. Expanded Medicaid does not have to include long-term care.

Offering a basic set of health benefits through an expanded Medicaid for all of our poorest citizens speaks to our values and makes good economic sense. But to get there, we need accurate information and political leadership.

Gina Upchurch

Executive director, Senior PharmAssist


The length limit was waived.

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