WASHINGTON — For most of her adult life, Amy Bielawski has gone without health insurance.
Her small Atlanta-area business, which provides entertainment for parties and events, didn’t bring in enough revenue to afford coverage. So she has gotten by on the hope that her high blood pressure doesn’t get worse and her small pituitary tumor doesn’t grow.
“I try to be as healthy as I possibly can so I’m not needing to run to the doctor, but there’s no backup plan when something goes wrong,” she said.
Bielawski, 56, is one of the people the 2010 Affordable Care Act, known as Obamacare, was supposed to help. But the Supreme Court in 2012 said the law’s Medicaid expansion provision had to be optional, and several Republican-led states refused to embrace it.
That left about 2 million people, mostly in Southern states, caught without any access to health coverage because they are considered too wealthy to qualify for Medicaid, which targets lower-income people, and too poor to qualify for Obamacare subsidies. In states like California, which expanded Medicaid under ACA, the gap is not a problem.
As congressional Democrats consider President Joe Biden’s “Build Back Better” plan, a sweeping bill to reshape the nation’s social programs, they are debating whether to finally close this Medicaid coverage gap, the most significant piece of unfinished business from the Democrats’ health law.
But it faces a mountain of challenges: The social safety net bill’s programs will probably be cut or curtailed to reduce the overall costs. Limited health care dollars are pitting Medicaid against other proposals to expand Medicare for everyone and ACA subsidies for middle-income people.
Sen. Joe Manchin III (D-W.Va.) says expanding Medicaid would allow for federal funding of abortion, a line he refuses to cross, even though other Democrats say it would not do so. And in the Senate, where Democrats have no margin for error, there are few advocates besides its most junior members.
“There are hundreds of thousands of my constituents who lack basic access to health care because my state’s Republican leadership refuses to expand Medicaid,” said Sen. Jon Ossoff (D-Ga.), whose surprise runoff-election win in January, alongside fellow Democrat Sen. Raphael Warnock, gave Democrats control of the Senate. “It is those voters who delivered the Senate majority.”
About 60% of the people in the gap in 2019 were people of color, exacerbating long-held disparities in health access by race.
“Democrats in the House and Senate all realize that solving for the Medicaid expansion gap is the single most important thing we can do for racial equity in health care in this bill,” said Leslie Dach, founder and chair of the health advocacy group Protect Our Care.
Early drafts of the bill would call for the ACA’s subsidies to be expanded to the Medicaid gap population for three years. By 2025, a federal program that mimics a state-run Medicaid program would provide coverage.
Manchin, who as the Senate’s most conservative Democrat is among its most closely watched, has two concerns about the Medicaid expansion. He is worried about how to pay for it and he says the Medicaid expansion would allow for the federal funding of abortion.
He insists that the longtime ban on federal funding of abortion, known as the Hyde Amendment, be added. But many other Democrats would oppose such a move. “I do not want to see the Hyde Amendment expanded in this bill, and I don’t see any reason why it should be,” said Sen. Patty Murray (D-Wash.).
Even if they wanted to, the Senate parliamentarian in 2017 said in an informal ruling that the Senate cannot add Hyde language to a bill passed through the special filibuster-proof procedure Democrats are using to enact their plan.
