http://www.nytimes.com/2013/10/03/health/millions-of-poor-are-left-uncovered-by-health-law.html?hp&_r=0
To summarize:
ACA obliges all but the poorest to have health insurance or pay a penalty.
The intention was this:
- . Medicaid would expand to cover more poor people (not just the poorest of the poor).
- . People with income between 138% to 400% of the federal poverty level would be eligible for federal subsidies to help pay the insurance premiums.
- . People with income over 400% of the federal poverty level would pay for their own health care.
- . People who, with the assistance of subsidies if applicable, could afford health insurance but had none would pay a penalty.
IF ACA had been implemented as planned, everyone would be able to have coverage. People earning less than 138% of the federal poverty level, it was assumed, would be eligible for Medicaid. Above that level, subsidies would make it possible for low-income people to afford coverage, and people earning over 400% of the poverty level would be able to pay for it themselves.
But then the ACA was challenged in the Supreme Court. The Supreme Court upheld the law but made the Medicaid expansion optional. As a result, 26 states rejected Medicaid expansion, whether out of political animus to Obamacare or simply because expanding Medicaid involves a financial burden for the state, all the more so if the state has a high proportion of poor residents.*
This opened a crack into which, according to the NYT article, about 8 million poor people have fallen: not poor enough for Medicaid, yet not earning at least 138% of the poverty level and hence ineligible for a subsidy. Because the states that have opted out are mostly southern and poor, this group includes two-thirds of the country's poor blacks and single mothers, and over half of uninsured low-wage workers.
Republicans will no doubt seize on this to criticize the ACA. They won't say so, but they would prefer to have no health care reform and therefore have many millions more remain uncovered.
One possible consequence: poor people migrating from the states without expanded Medicaid to those with expanded Medicaid. But it's not easy to move and organize a life elsewhere if you're living hand to mouth.
* That said, the federal government will pay for the expansion through 2016, and at least 90% going forward after that.