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'Gap’ in coverage leaves some without health insurance

Linda Berman was forced to file for personal bankruptcy in 2012 after a four-day stay in the hospital left her with thousands of dollars in hospital bills.

So the 63-year-old Lake Dallas resident, who is diabetic and has been without health insurance since 2009, hoped she could find affordable insurance once the federal health exchanges opened under the Affordable Care Act. But she says it’s still too expensive.

Berman, a self-employed performer who uses bubbles to educate children about math and science at area libraries, learned that she is one of millions of Americans who have fallen into a new unintended coverage gap created by the healthcare law and by Texas leaders’ decision not to expand Medicaid.

Berman said she makes too much money to be eligible for Medicaid, but too little to qualify for federally subsidized insurance under the Affordable Care Act, widely known as Obamacare. Without a subsidy, she said, she would have to spend $600 to $800 a month on premiums for a plan that would meet her needs.

The new Medicaid gap was created after Texas leaders chose not to expand its Medicaid program, and the U.S. Supreme Court upheld the state’s right to make that decision under the healthcare law.

In Texas, it’s estimated that more than 1 million people fall into what is being called “the new doughnut hole,” said Dennis Borel, executive director of the Coalition of Texans with Disabilities in Austin.

“What you got is people who are too low-income to qualify for stipend assistance [under Obamacare] but the state chose not to provide Medicaid for them,” Borel said.

Texas and about two dozen other states chose not to expand Medicaid coverage. Gov. Rick Perry has remained adamant that the state won’t pump more taxpayer dollars into Medicaid, which he says is riddled with inefficiency and other problems.

“It would be reckless and irresponsible,” Perry’s spokeswoman Lucy Nashed said.

An estimated 3 percent of Texans fall into the gap, she said.

Fight for coverage continues

Texas Medicaid, which is funded by the state and federal governments, basically covers low-income children, seniors, people with disabilities and pregnant woman. A family of three can make up to $3,255 a month and qualify — but only the child or pregnant woman is covered. For adults in the household to be covered, that family of three would have to make no more than $251 a month, according to the state’s Health and Human Services Commission.

When the Affordable Care Act was signed into law in 2010, it envisioned expanding state Medicaid eligibility up to annual household incomes of 133 percent of the federal poverty level, which is $11,170 for an individual and $23,550 for a family of four.

Opponents of Medicaid expansion say their objections have nothing to do with not wanting to help the working poor. Nor is their opposition due to a desire do away with Medicaid, they say.

The hope is that state and local governments would take over control of such programs “to make sure the money is going to the people who really need it,” said Ross Kecseg, Dallas-Fort Worth policy watchdog for Texans for Fiscal Responsibility, a conservative think tank in Austin, which advocates for fiscal stewardship.

Also, Kecseg said, by offering Medicaid to more of the working poor, it’s letting private companies off the hook, he said.

“It’s basically saying we don’t want employers and companies to pay for health insurance,” Kecseg said.

Meanwhile, groups that advocate on behalf of the uninsured, including the Houston-based Texas Organizing Project, say the fight is not over for those who need coverage. The group has been meeting with legislators in Austin to increase awareness about the need to help more Texans, said Tiffany Hogue, statewide healthcare campaign coordinator for the group, which advocates affordable healthcare.

“We have over 1 million people who don’t have options for affordable health coverage,” Hogue said. “It’s taken a while to raise this to a level of everyone’s consciousness, but that’s exactly what we’re doing.”

Caught by surprise

Barbara Price of Fort Worth got hit with news last winter that her 41-year-old son, who was born with minor brain damage, made too much money at Albertsons last year to remain eligible for Medicaid. Tom Price, who stocks and loads merchandise at the store, was told he would lose his Medicaid coverage because he no longer qualified for federal Supplemental Security Income payments.

After numerous calls to Social Security over several weeks, Barbara Price was told that her son’s Medicaid coverage would be reinstated in February, and it was, she said.

But the family wonders what will happen next year. Might he fall into the Medicaid gap again? Will his benefits be disrupted again?

“Are we going to go through this again and again?” she said. “We’re in, we’re out. Which is it?”

The disruption is a real cause for concern, Borel said.

“Here’s a guy who has a brain injury and now he’s working at a grocery store. He’s probably doing a lot of physical work, bagging groceries, stocking shelves, chasing carts all over the parking lot,” Borel said.

“He’s out there trying to make his own way,” he said. “And instead of having policies to promote people to become more self-reliant, we punish them.”

Berman, who is now working with the Texas Organizing Project to raise awareness on the issue, lost her individual health insurance about seven years ago when she moved to Texas from California. Her former insurance provider did not do business in Texas, she said.

She was denied coverage because of her pre-existing condition, and her only alternative was to take part in the state’s high-risk pool, she said. But when the monthly premium climbed to $1,300, she decided she could no longer afford it and dropped the coverage in 2009.

She loves her job performing for children, even if it has left her in a coverage gap.

“It’s very rewarding,” said Berman. “But it’s not a way to make a lot of money.”

She depends on lower-cost oral medications to manage her diabetes. But she worries that her medical costs will rise as she gets older.

“I wish they would get all the politics out of the middle of this,” Berman said. “If they [lawmakers] would just look at the fact that 1 million people would benefit and would be living healthier lives, if all they would do is to allow us to have Medicaid.”

This report includes material from the Star-Telegram archives.


A few economic studies have touted the benefits of expanding Medicaid in Texas.

     If Texas were to participate, the Fort Worth-Arlington area would receive a $22 billion boost in business activity over the next 10 years, according to a February 2013 study by The Perryman Group in Waco.

     The move would also free up private funds and reduce uncompensated care of local safety-net hospitals, Perryman said.

     The economists also said that it would be good news for worker productivity.

     “When individuals lack health insurance and their access to care is constrained, empirical evidence indicates they have worse healthcare outcomes and, hence, reduced labor force participation, higher absenteeism and lower productivity,” Perryman said.

Source: Texas Should Participate in Medicaid Expansion Under the Affordable Care Act, The Perryman Group, February 2013