Conrad Theodore Seitz

An ironic and outrageous situation has developed over the last year, quietly punching an enormous loophole in the Affordable Care Act.  First, the Act separated people into Medicaid-eligible and “middle class” categories and mandated an enormous expansion of Medicaid.  The “middle class” category was expected to buy health insurance, on an exchange, and would be qualified for subsidies of the premiums as necessary.  Those who had incomes below a certain level would be covered by Medicaid and not expected to buy health insurance nor to pay the ten to forty percent copays that the exchange insurance required.

Then, the Supreme Court ruled that expansion of Medicaid, a state by state operation, was not mandatory.  Those states who did not wish to participate could opt out, regardless of the effect on their indigent populations.  Twenty-six states have so far opted out.  This includes about half of the population of the United States, but 60 percent of its uninsured working poor people.  Most of the states that have opted out are in the deep South; in fact, nearly all deep South states except for Arkansas are not with the program.

States that have opted out have no medical coverage for people who are below a certain income level but not eligible for Medicaid.  Few people are aware that, in most cases, those who do not have dependent children are not eligible for Medicaid.  Poor people are not eligible to purchase insurance on the exchanges either, even if they could find the money to pay the premiums.  As a result, eight million poor people are caught in this “doughnut hole.”  This includes, according to the New York Times, 435,000 cashiers, 341,000 cooks, and 253,000 nurse’s aides.

The irony of this situation is more than a thinking person can bear.  The law, as originally conceived, would have affected every state and included all of the people.  As a result of the Supreme Court decision making it voluntary, half of the country is not covered, and that half includes a disproportionately large percentage of poor people, black people, and especially poor, black people.  This is an entirely irrational result, so outrageous that anyone who really understands it is immediately and profoundly discouraged about the future of health in this country.

If this situation is not resolved– and it likely will not be– there will be more people crowding our emergency rooms with no insurance who have had no care for their chronic and ultimately disabling health conditions, people who could have avoided a stroke or a heart attack with simple, cheap prescription medicines, people who could have had their schizophrenia or bipolar disorder managed well enough to prevent them from violently acting out or causing motor vehicle accidents, people who could have avoided kidney failure and diabetic gangrene of their extremities with medicines that have been available for almost a hundred years.

This result is entirely the fault of Republicans who prevented a single-payer, universal coverage health insurance legislation from even being voted on.  It is also the fault of Republican Supreme Court judges who thought they would have a little fun dissecting Obama’s law, turning it from a mandate into a tax and eviscerating the most important part: providing health care to poor people.