by Daniella Silva and Timothy Weisberg
Elihue Claiborne will have healthcare for the first time at the age of 43. He was one of over 600,000 uninsured Alabama residents until a faith-based advocacy group in Birmingham stepped in and helped him get coverage.
“I qualified for it and I’m glad I came to get the program,” said Claiborne. “Then I came for my mom and got her signed up.”
Claiborne learned he and his mother now qualified for health insurance under the Affordable Care Act at Greater Birmingham Ministries, which offers community services such as food and clothing drives for Birmingham’s impoverished as well as education sessions on issues ranging from healthcare, obtaining WIC and food stamps, how to obtain Alabama state identification, register to vote as well as keeping them up to date on policy changes.
Claiborne’s mother, who is in her late 60s was diagnosed with terminally ill cancer and could not afford to get treatment. Now, he is hopeful that both he and his mother will have greater access to the health care providers and medication they need.
“It’s a blessing,” he said. “It’s really a blessing.”
The Affordable Care Act mandated that people living below 138 percent of the federal poverty line, about $27,000 for a family of three, could now receive Medicaid regardless of preexisting health conditions. But experts say old structural issues remain in the way of providing quality care for the nation’s impoverished. For those who do fall under expansion guidelines, access to healthcare providers who accept Medicaid is still a major issue in Alabama and states throughout the nation. But many may still not receive coverage at all, with states choosing not to expand their services.
In a June 2012 ruling, the Supreme Court gave states the option to opt out of the ACA’s Medicaid expansion. Currently, 15 states have chosen to opt out, leaving over 5 million people in a coverage gap, where they cannot have access to Medicaid or qualify for coverage or tax credits under the federal health exchange.
“I’m not sure if the federal government knows what to do with this population, because this law is written in a way that it puts them in a tricky spot that they’re ineligible for subsidies,” University of Alabama at Birmingham (UAB) Associate Professor of Public Health David J. Becker said.
Becker said the state’s decision not to expand Medicaid creates a “donut-hole” in health care coverage for those who need it most.
“Last time I checked if you’re thinking about a real comprehensive health care bill that’s going to change the nature of the U.S. health care system, you would think there would be something for the poorest Americans,” he said. “And currently there is not.”
Nationally, the coverage gap represents over a quarter of the uninsured population in states not expanding Medicaid, according to a study by the Kaiser Foundation. In Alabama, that percentage is as high as 36 percent, the second highest in the nation.
“You’ve got a lot of people that just fall into that gap in Alabama that work, but they might not be getting enough as far as salary goes to qualify,” said Stan Johnson, an independent contractor with the non-profit Alabama Arise. “We have a lot of people who are trying, but they just don’t make enough.”
While organizations like Alabama Arise and Greater Birmingham Ministries have started education and enrollment campaigns, they continue to have to turn people who would otherwise qualify under Medicaid expansion away.
“I think we’ll see people that are lost by the wayside, folks who are going to fall through the cracks,” said Mary Jones, co-coordinator of Direct Services at GBM.
“The people that come here are like myself, who are not able to get the medication that is required for their illness, they go without it,” she said. “I go without medication.”
According to a 2012 study co-authored by Becker on the economic effect Medicaid expansion would have in Alabama, expansion would reduce the state’s uninsured population by approximately 232,000 individuals while generating $20 billion in new economic activity and a $935 million increase in net state tax revenues. But in spite of these reported benefits, Becker said many Republican state legislatures remain skeptical of how much the bill would cost states in the future.
Under the ACA, the federal government covers all Medicaid expansion costs from 2014 through 2016. States would still be responsible for some administrative costs, but the federal government would almost entirely foot the bill for the first three years of implementation. Federal government funding would decrease on a sliding scale after 2016 to 90 percent of all costs by 2020, according to Becker’s study.
“There’s some uncertainty [in states] if the federal government shirks its responsibility then what are we left to do?” Becker said. “Are we going to be able to withdraw from this program or not?”
Even if Alabama chose to expand Medicaid, local clinics said the newly insured would still lack access to medical services.
“If Medicaid expands in our community, that’s not a silver bullet to poverty,” Executive Director of M-Power Ministries Ryan Hankins said. “There are simply not enough Medicaid providers to serve the population.”
Chris Monceret, Executive Director of the Community of Hope Health Clinic in nearby Pelham, Ala., echoed Hankins’ sentiments about access, regardless of whether people receive Medicaid under ACA.
“If you have someone in rural Shelby County, and their only medical provider is 70 miles away, and they don’t have transportation, then essentially they don’t have an insurance provider,” she said.
“We’re going from no health insurance and no access, to some health insurance with still no access,” said Laura Washington, health center director at M-Power Ministries.
The clinic serves uninsured patients at 200 percent or above the federal poverty line, and thus most would qualify under Medicaid expansion, said Hankins.
“We find ourselves on the one hand being pushed to advertise and market these services to the population knowing that very few of them actually qualify for the exchange,” he said.
Hankins added health care was a means to an end, with the goal of ultimately curtailing “generational poverty.”
“The population that we serve come to us with health concerns, but those are often masked or masked by educational deficits, employment deficits, etc.,” he said, noting that many patients are wary of getting treatment from traditional medical personnel.
Becker said the issue of access was inherent in the way the healthcare system was structured before the ACA.
“The question is what do we want Medicaid to be like, what level of care are we providing to those that can’t provide for themselves?” he said. “We didn’t have a coherent discussion about willingness to pay.”
Even for those uninsured who are eligible for coverage under the online health exchange, Healthcare.gov has been riddled with delays and technical glitches, distracting the public from what Becker says is the bigger issue in providing healthcare.
“I think it would be much better if Americans were aware of this gap population rather than whether a web site is functioning properly” he said, adding that many people now have a misconception that the ACA is providing insurance for the poor.
For Claiborne, who says he is fortunate that he qualified for coverage under ACA, there are many people he has encountered at GBM who were turned away because they did not make enough.
“It’s not right,” he said. “It’s not right at all. Everybody’s got a falling point in their life.”
For a population that has been historically underserved, Hankins said the complexities of healthcare reform are confounding an already complex set of issues.
“It’s really a perfect storm of an under resourced community serving an under informed population with additional confusion at all levels of the healthcare system,” he said.