Some uninsured parents face health-insurance 'crater'
BY RON J. JACKSON JR. Oklahoma Watch
Sunday, January 13, 2013
1/13/13 at 4:36 AM
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They deserve better
The health-care fate of tens of thousands of low-income parents is in limbo because of Oklahoma's refusal to accept federal money to expand Medicaid.
So far, much attention on Oklahomans who will not gain access to Medicaid in 2014 under the federal health law has been on adults without children. That group makes up most of the roughly 200,000 Oklahomans of working age who would have been covered if Gov. Mary Fallin had agreed to expand Medicaid, the government program that provides health coverage for the poor, the disabled, children and others.
But also excluded from the Patient Protection and Affordable Care Act will be as many as 50,000 Oklahoma parents with dependent children living at home, according to one study by a nonpartisan research group.
That represents about a fourth of all low-income adults ages 19 to 64 who would have qualified for expanded Medicaid - the 13th-highest share in the nation, according to a study by the Urban Institute, a nonprofit group based in Washington, D.C.
A result is that uninsured parents remain on edge. Although their children may get health insurance through federal or state programs, the parents' health remains critical to the family's overall well-being.
Greg and Keta Rogers of Del City are among those parents.
The couple, who have three children at home, do not qualify for the state's Medicaid program, called SoonerCare, because their income is too high. They would have been covered under an expansion of Medicaid, but Fallin's decision will leave them out.
The Rogerses also may have no options for coverage next year. That's because their income falls just below the minimum required to buy subsidized coverage on a new federal health exchange - an online market where people and businesses will shop for insurance - that will serve Oklahoma. They fall into what's being called a "crater": too much income to get Medicaid, too little to buy heavily subsidized coverage on the exchange.
Unless something changes by 2014, the Rogerses will be stuck. Greg Rogers, 40, questions Fallin's decision.
"Why would someone turn down federal money that was going to help with the health of thousands upon thousands of people? It just doesn't make sense," he said of the governor's decision to reject federal funds to expand Medicaid.
Greg Rogers said the lack of insurance causes him to avoid going to the doctor. He said private doctors won't see him because he can't afford the fees.
Keta Rogers, 38, lost her medical coverage last year when she was laid off.
"There have been days when I felt too sick to get out of bed," said Greg Rogers, who works for a small insulation company that doesn't provide health insurance. "But I can't afford to miss work. My family is counting on me. So I drag myself out of bed and do what I have to do to take care of my family.
"One day I was so sick, I finally broke down and went to the emergency room ... It cost me $1,000 for a $30 prescription."
Options for the uninsured
When Fallin announced her decision in November, she said the state could not afford Medicaid expansion and would become more dependent on federal money that might not be available in the future.
Alex Weintz, a spokesman for Fallin, said recently that the governor wants to work with lawmakers, businesses and the health community to find other ways to provide affordable access to care, but it is too early to provide specifics.
"We know that we need to improve our health as a state," Weintz said.
Insuring more families is part of the answer, but sustaining economic growth and reducing preventable illnesses also are important, he said.
Without expanded Medicaid, questions remain as to what options the uninsured poor will have.
The Affordable Care Act offers two main avenues to health insurance coverage starting Jan. 1, 2014. One is through Medicaid expansion, encompassing those with incomes up to 133 percent of the federal poverty level, currently $30,657 for a family of four.
The other is through a government health-care exchange where people can shop for plans online. People making between 100 percent and 400 percent of the poverty level can buy insurance on the exchange using tax credits to cover most of the cost. Fallin decided not to set up a state health-care exchange for Oklahoma, so a federal one will serve the state instead.
Oklahomans who would have been eligible for expanded Medicaid are a diverse group, according to the Urban Institute study, released in August. More than half are between ages 19 and 35, and more than three-fourths live below the federal poverty level, which is $11,170 for an individual and $23,050 for a family of four.
About 60 percent are white. About 24 percent are parents, compared to 18 percent nationally, the study found.
The study pegged at 225,000 the total number of Oklahoma adults who would have gained coverage under expanded Medicaid. The Oklahoma Health Care Authority estimates the number at about 200,000.
William Noel, pastor of Grace and Glory Baptist Church in northeast Oklahoma City, which sponsors a free clinic, said many people would be surprised at the variety of uninsured Oklahomans.
"These aren't homeless people who don't have jobs," he said. "In our free clinic, we see people all the time from various professions - teachers, small-business owners and a lot of truck drivers.
"In fact, I don't have insurance," added Noel, saying his church can't afford the coverage.
Low-income adults are most at risk of being uninsured. They generally do not qualify for Medicaid. To qualify, they must fit a specific category, such as being pregnant or disabled. That is the case in most states.
Ineligible adults include many parents. For a family of four in Oklahoma, non-disabled parents must make $6,996 or less a year to get SoonerCare, unless they fall into one of the categories.
"Basically, for parents to qualify for SoonerCare, they have to be essentially destitute," said Carter Kimble, a spokesman for the Oklahoma Health Care Authority.
The Urban Institute estimated that 53,000 parents in Oklahoma would have gotten Medicaid with the expansion. About 60 percent of those are in the "crater," so they won't be able to buy affordable coverage on the health exchange.
Without Medicaid or employer insurance, uninsured parents and other adults have relatively few options:
Weintz, Fallin's spokesman, said the governor is looking at expanding Insure Oklahoma to offer more affordable care. But on Jan. 1, 2014, Insure Oklahoma will lose nearly two-thirds of its government funding when federal matching money stops, said Jo Kilgore, a spokeswoman for the state Health Care Authority.
- They can obtain coverage through Insure Oklahoma, which offers subsidized plans to individuals and workers at small businesses. The program is now limited to about 35,000 enrollees, and participating businesses must have a qualified health plan.
Said Weintz: "We're hoping that won't happen, but it is true that funding for that is in jeopardy."
In general, for Oklahoma parents and others in the "crater," the prospects for getting coverage look bleak, some health experts said.
- An insured worker at a business with fewer than 25 employees can seek discounted coverage through an Affordable Care Act program. But the employers must meet certain criteria and do not have to participate.
- People who earn between 100 percent and 400 percent of the poverty level can use tax credits to purchase coverage from the health exchange in 2014. The poorest of that group will pay no more than 2 percent of their income on premiums, as well as get a subsidy for other health costs.
- The uninsured can continue seeking health care at hospital emergency rooms or free clinics around the state.
"Is help on the way?" said Robin Rudowitz, associate director of the Kaiser Commission on Medicaid and the Uninsured. "No ... states that turned down the money (for expanded Medicaid) have now missed a major opportunity to help those who otherwise can't afford health insurance."
The family's options
The Rogerses ran into trouble a year ago when Keta Rogers was laid off from the Del City Housing Authority. She was six months' pregnant at the time, so she qualified for temporary assistance from SoonerCare.
Today, the couple's three children - Maeahja, 14; Elisha, 12; and Triumph, 10 months - are all covered by SoonerCare.
But Greg and Keta Rogers don't qualify. Greg Rogers' annual income of $27,000 is well above the $8,184 limit for parents in a family of five to get Medicaid and just below the federal poverty level. His employer has seven workers and doesn't offer health insurance.
The couple's best hope may be to raise their income to just above the poverty level, so they are in the window of between 100 percent and 400 percent that allows them to get discount coverage on the health exchange. This could become a goal for thousands of Oklahomans living just below the poverty line.
One risk is that the subsidies could go away if a lawsuit filed by Oklahoma Attorney General Scott Pruitt is successful. The lawsuit contends that the federal health law is worded in such a way that subsidies can be offered only through state exchanges, not the federal one that Oklahoma will have.
Greg Rogers is already trying to boost his pay. He awakens at 5 a.m. and works at his full-time job until about 3:45 p.m. He then attends classes as part of a three-year apprenticeship that will ultimately earn him a certification that can lead to higher pay. The apprenticeship costs $27,000.
"I remember one day a man (from an outside insurer) came to talk to us at work about signing us up for health insurance," Greg said. "I knew I couldn't afford it before he even began to talk. Right now, I have money taken out of each check to pay for the apprenticeship. We need every penny I make just to get by.
"I'll be honest, I worry a lot about my health. I pray nothing happens to me. If something did happen, it would be devastating to my wife and kids."
Subsidized coverage: Who's in, who's out
Without Medicaid expansion in Oklahoma, roughly 200,000 people, mostly adults, will remain ineligible for the program. Among those are tens of thousands of parents. Many of these parents and others, totaling anywhere from 130,000 to 170,000 people, will be stuck in a crater next year, earning too much to get Medicaid but not enough to qualify to buy subsidized coverage on a federal health exchange, an online insurance market. Here's an example of what a low-income Oklahoma family with two parents and two children will face, based on figures from 2012. The children are already covered by Medicaid.
* If the parents earn $6,996 or less: They're eligible for Medicaid.
If the parents earn more than $6,996 but less than $23,050 (100 percent of the federal poverty level): The parents are stuck in a "crater," earning too much to get Medicaid and too little to qualify for buying on the federal health exchange using tax credits that cover most of the cost of premiums.
If the parents earn more than $23,050 but less than $92,200 (400 percent of the federal poverty level): The parents are not eligible for Medicaid. However, they can purchase subsidized insurance on the federal exchange. Depending on their income, their cost of premiums will be capped at anywhere from 2 percent to 9.5 percent of their income. Those earning up to 250 percent of the poverty level will also get subsidies for other costs, such as deductibles, co-payments and coinsurance.
Sources: Oklahoma Health Care Authority, Urban Institute.
Oklahoma Watch is a nonprofit investigative reporting team that covers important issues facing the state.
Keta Rogers was laid off from the Del City Housing Authority a year ago but had health coverage while she was pregnant with daughter Triumph, now 10 months old. Rogers is now uninsured. HEATHER BROWN / Oklahoma Watch
Maeahja (left), 14, the Rogerses' eldest, plays with cousins Toriana and Ty'Sheauna Pennon and Keta Rogers' sister Maeisha Pennon. HEATHER BROWN / Oklahoma Watch
Keta Rogers cooks with her 14-year-old daughter, Maeahja, who, along with her two siblings, is covered by government-provided insurance. HEATHER BROWN / Oklahoma Watch