In the sometimes wacky ongoing drama called Life with the Affordable Care Act, many low-income patients who live in one of the 23 states declining to expand Medicare coverage are left in a painful catch-22.

A recent Washington Post blog piece uses a graphic illustration to demonstrate the gap. “These charts are a pretty strong illustration of what’s known as the “coverage gap” in states that opted not to expand Medicaid, which the Supreme Court allowed them to do in a 2012 ruling,” wrote the Washington Post.

“According to Kaiser estimates in their recent report Modern Era Medicaid: Findings from a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP,  as of January 2015 there are nearly four million people who earn too much to qualify for Medicaid in these 23 states, but they also earn less than the federal poverty level, which is the minimum income requirement to qualify for premium subsidies on Affordable Care Act (ACA)’s health insurance exchanges.”

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Let’s break this down a little more clearly. As of January 2015, states that did expand Medicaid coverage offer expanded coverage to families of three with incomes of up 138% of the 2014 federal poverty level (FPL). With the 2014 FPL at $19,790, this would provide Medicaid coverage for a family of three making up to approximately $27,000 per year.

In states that opted not to expand Medicaid coverage, the cut-off income varies from state to state. In Texas, the largest state to opt out of Medicaid expansion, a family of three must have an annual income of less than less $3,760.

Put it even more starkly — if your patients are a family of three living in Farwell, Texas, they must make less than $3,760 annually to be eligible for Medicaid. Their neighbors, living less than 100 yards away in Texico, New Mexico, are eligible for Medicaid making almost ten times the Farwell, Texas limit — up to an annual income of $27,000 per year.

Well, you might say, patients who are not eligible for Medicaid have the ACA to fall back on. Your patients in Farwell, Texas can just get covered by Obamacare.


The ACA has a bottom limit for eligibility, meaning that patients making less than certain amounts are not eligible for the ACA. (I don’t know this, but I am guessing that such a lower limit was an effort to prevent states from opting out of shared responsibility to provide care for their citizens.) For example, let’s take the family that comes to your clinic living in Farwell, Texas, and let’s say they have an annual income of $10,000, which is way below the 2014 federal poverty level for a family of three of $19,790.

Because the government of the state of Texas has decided to decline participation in Medicaid expansion (here’s a map of which states are in and which are out), your Farwell, Texas patients are out luck. They make too much for ACA eligibility, and three times the amount allowed to qualify for Medicaid eligibility in Texas. If dad has a myocardial infarction, daughter is injured in a motor vehicle accident, or mom gets breast cancer — these patients are toast.

Meanwhile, just across the street, our New Mexico family getting by for a family of three on less than $29,000 a year has full Medicaid coverage. The difference in health coverage between the neighboring households is simply because the government of one state selected to participate in the expansion of Medicaid, while the government of the other did not.

Much has been written about the important role of residence in health, and this is a stark example of the difference just a few feet can make in the health of our patients, our ability to assist them in avoiding illness and injuries, and treating them when they occur.

Jim Anderson, MPAS, PA-C, ATC, DFAAPA, is a physician assistant in Seattle, WA.