The Coverage Gap(s)

The Patient Protection and Affordable Care Act—also known fondly as “Obamacare”-- was passed back in 2014 with the primary goal of increasing the number of insured Americans. Not surprisingly, the law worked; since the ACA took effect in 2014, more than 16.9 million Americans now have health insurance (1). Medicaid eligibility expansion plays a huge role in this coverage, since the ACA allowed nearly all low-income individuals with incomes at or below 138% of the poverty line ($16,243 for a single person, or $27,725 for a family of three in 2015) to now receive coverage through Medical Assistance (1). Well, that is in the 31 out of 50 states that chose to expand Medicaid eligibility. Luckily, Pennsylvania is one of the states that have given their most vulnerable populations the ability to access quality medical care coverage. But what about the other states that have chosen not to expand?

This has been an issue addressed many times over. Medicaid expansion was intended to extend insurance coverage for low-income individuals, while “Marketplace” coverage would insure people with moderate incomes by providing premium tax credits for enrolling in coverage. But because 19 states have chosen not to expand coverage, there now exists the “Coverage Gap,”-- in states that do not expand Medicaid, many adults have incomes too high for Medicaid eligibility but too low to qualify for the Marketplace premium tax credits [See Figure 1] (2). If these States would choose to expand their Medicaid eligibility requirements, 2.9 million people would become eligible for Medicaid, while another 1.8 million people currently covered by Marketplace eligibility would gain access to Medicaid (2).

This is an extreme example of the type of coverage gaps that exist in our healthcare system today.  Every day in service, I witness what being uninsured and underinsured means for an individual. In providing enrollment services for obtaining prescriptions, I interact with patients who are trying to work in the system with partial to no insurance coverage at all. Oftentimes even when a patient has full insurance, he cannot obtain a medication he desperately needs because his co-pay is too costly or his insurance won’t approve a specific brand. I’m constantly faced with the uphill battle of insurance company denials for coverage, my patients’ ineligibility for public services, and trying to navigate a health care system that, even as a trained provider, I find difficult to circumvent.

In an ideal scenario, my position would be obsolete—every American would have high-quality health insurance, including comprehensive prescription coverage. In this ideal world, I would not need to assist under-insured patients in finding ways to afford their medications because their insurance would provide the necessary care that is required. To see a low-income patient pay an immense portion of her income every month towards an insurance premium just to find she has to meet a $2,000 dollar deductible before her partial co-pay kicks in for her $1,300 dollar life-sustaining medication -- well, there is just something extremely wrong with that scenario.

For now, my service provides temporary assistance to these patients. Everyday I witness the gaps in insurance coverage and recognize there is a great need for reformation in our healthcare system. While I know that my service is immensely helpful to my patients and I have valued this opportunity to serve them, the justice of improved healthcare-- closing the coverage gaps that prevent my patients from achieving good health -- would be exceedingly more effective than any form of assistance I could provide.

(1). http://www.healthline.com/health/consumer-healthcare-guide/how-does-the-...
(2). http://kff.org/health-reform/issue-brief/the-coverage-gap-uninsured-poor...

This blog post was written by NHC Philadelphia member Ellie Malfaro.
Ellie serves as a Patient Advocate at Philadelphia Department of Public Health-Ambulatory Health Services: Strawberry Mansion Health Center.