The coverage gap

As you may know, the intent of the Affordable Care Act was to get people below a certain income level onto Medicaid, with people at or above that income level receiving subsidized health insurance via the exchanges. Unfortunately, when the Supreme Court ruled that the Medicaid expansion mandate was unconstitutional, it meant that in states that refused to expand Medicaid people who fell below that income level but above the income level for Medicaid eligibility as things were would be left out of coverage – too poor to receive insurance subsidies, not poor enough for Medicaid. More than one million Texas adults fall into that coverage gap. Here’s a story about one of them.

It's constitutional - deal with it

It’s constitutional – deal with it

Damaged discs in Irma Aguilar’s neck make it hard to raise her arms, something she must do repeatedly when stacking boxes at the pizza restaurant where she earns $9 an hour as an assistant manager.

Sometimes, her untreated high blood pressure makes her so dizzy she has to grab onto something to prevent a fall.

And she struggles with anxiety, a heart-pounding fear that can strike at any time, but especially at night, when she lies in bed and wonders how she’s going to make ends meet.

Without insurance, she worries about how she will find the money to treat her health problems, which threaten her livelihood and the well-being of her family.


Aguilar’s four children are covered by Medicaid, which provides free or reduced-cost health care. But Aguilar makes too much money – $19,200 a year – to qualify. Texas’ Medicaid eligibility requirements are among the tightest in the nation, and Aguilar has to be nearly destitute to meet them – making no more than $4,200 a year as head of a family of five.

Emphasis mine. What that means is that if you make more than two dollars an hour working fulltime, you make too much money as the head of a family of five to qualify for Medicaid in Texas. Think about that for a minute.

Still left out of Medicaid, Aguilar hoped to get insurance under the ACA, but to qualify for a tax credit to help her pay for it, she would need to earn more than she does – at least $27,570 a year. Only those earning between 100 percent and 400 percent of the poverty level are eligible for the subsidies. Aguilar is at 70 percent.

This puts her in the gap, with neither Medicaid nor affordable health insurance.

If she could get a subsidy, Aguilar would have shelled out about $46 a month for a midlevel health plan. Without one, the cost would have zoomed to more than $200 a month, a price that puts health insurance out of her reach.

“I have to scrape by as it is,” Aguilar said. “By the time I pay rent, lights and water, there’s not much left over. Sometimes, I don’t eat so my kids can eat.”


As Texas rejected the extra Medicaid money, state lawmakers committed more resources to health care in the past session, said Stephanie Goodman, a spokeswoman with the Texas Health and Human Services Commission.

The Legislature set aside $100 million in added money for primary care services for women and an additional $332 million for mental health services, she wrote in an email.

“We’ve also developed a strong network of health centers across the state that provides low-income citizens with access to both preventive care and treatment for medical issues,” she said.

Such clinics depend on a mix of revenue – Medicaid, private insurance and patient fees – to enable them to provide care to those who lack insurance.

But those front-line providers don’t have enough money and resources to care for all the uninsured, including those in the coverage gap, said José Camacho, head of the Texas Association of Community Health Centers.

Nor can health centers provide a broad range of services, making them a too-porous safety net, others say.

“They’re no substitute for not having coverage,” said Anne Dunkelberg, a policy analyst at the Center for Public Policy Priorities, which advocates for low-income Texans. “They can’t provide specialty treatment or trauma care. If you’ve been hurt in a car wreck or have a broken bone or cancer, if you need a CT scan, you’re going to be out of luck. Health centers are wonderful for primary care, but they’re not a substitute for comprehensive care.”

Ms. Aguilar has chronic conditions, as noted above, so these health centers likely wouldn’t be of much good to her anyway, assuming she could afford their fees. Even if she could, she wouldn’t be able to afford any medications they might prescribe. So she’s pretty much SOL. I personally think that Rick Perry, David Dewhurst, Greg Abbott, Dan Patrick, Ted Cruz, and everyone else responsible for Texas’ horrible lack of health insurance for so many of its residents should be made to personally explain to Ms. Aguilar and her kids why they don’t want her to be able to get health care. Not that I think it would have any effect on them, but maybe if they had to explain it to all one million plus Texans that they have excluded from coverage it might eventually wear them down.

I do know one way that Ms. Aguilar and the million others like her could get helped, and that’s by electing Wendy Davis and Leticia Van de Putte this November. No guarantee that they’d be able to overcome legislative resistance, of course, but there was some sentiment for expansion in 2011, and at least they wouldn’t be adding to that resistance. And if the Lege still can’t stand the idea of expanding Medicaid, there’s another way they could help Ms. Aguilar and many others like her: Raise the minimum wage. If Ms. Aguilar earned a bit more than $13 an hour, then her fulltime salary would make it to that magic $27,500 level – which is to say, exactly at the federally defined poverty line – and she’d qualify for insurance subsidies on the exchange. Either way would be fine by me.

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One Response to The coverage gap

  1. Loomy says:

    I live in a country that elects its politicians to represent their best and common interests and as such, the Politicians we elect are acknowledged as Public Servants…they are tasked to serve the Public who voted them in.

    And …THEY DO! This carries through to BOTH sides of Politics as (obviously…) they serve the same Public and therefore, MUTUALLY AGREE on many of the basic tenets of society and in serving the citizens they represent, who ALL have the same dreams, hopes and aspirations.

    Perversely, America does not. Nor do their Politicians.

    Frankly, if ANY politician was responsible for or unwilling to have 1 MILLION Citizens covered for and receiving Health care/Insurance, they would not only be voted out, they would be JAILED.

    Seriously, such behavior is considered a criminal offence…though not in America, it seems.

    The fact that you have Politicians that actively attack, hurt and disadvantage in terms of Health, wages, benefits and opportunity the more disadvantaged sections of your Society is largely considered morally bereft , especially as it creates more poor and more suffering to these people.

    To even consider that these things are done at the behest or for the perceived benefit of a minority of Citizens who are by far and away wealthy beyond most others imagining is scandalous and again would be subject to investigation if seen or suspected.

    To do these things to Citizens for or to benefit corporations or Business interests…inconceivable

    That’s right. We can’t even imagine it being done…it just does not compute.

    Your Minimum wage is LESS than it was in 1968, no guaranteed Maternity leave, sick leave or Holiday leave…

    41 Million without Health Care…


    It sounds as if the American Worker is living in the 19th Century…what the hell?

    And why has it been allowed to get this way (or should I say STAY this way)

    But …I guess that is why you have one of the most unequal and unfair gap between your richest and poorest than most any other country. Why the richest 450 Americans have more than the poorest 150 MILLION Americans.

    Where you blame and attack the Poor under the orders of those who want even More.

    It is shameful. What’s worse, it is so unnecessary if it weren’t for the selfishness and willful greed of a privileged few who in all actual reality , would hardly miss the money they have , that could be used to change the lives of so many.

    Better still, they were just willing to give those less well off , the chance, fairness and equity that should have been given/available to them in the first place.

    As we have done and continue to do, as well as most others do…but America still won’t.

    Go Figure, huh?

    I hope for all your sake, you come to your senses and do the right thing.It is easy to do, you just need to Want to .

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