Kansas State University


Issues in Health Reform

Category: The uninsured

What does it mean when politicians say health care is a right?

Of late President Obama and others have been touting the recent Supreme Court (SCOTUS) decision in King v Burwell that upholds tax subsidies for every state as proving health care is a right. Hmmm. That’s still a stretch. Let’s look at who is likely to either have health care paid for with the assistance of insurance, or have health care directly provided to them and who is still left out.

We have the public plans that do make health care a right for those who fit the eligibility criteria. There is:

  • Medicare for those over 65, the disabled, and selected other special disease interest groups (End Stage Renal Disease, Lou Gehrig’s disease).
  • Medicaid for those poor enough who are over 65, or under 19 (those who are in the state Children’s Health Insurance Programs (CHIP)), and now adults under 138% FPL ($27597 for family of four) in the 31 states that have expanded their Medicaid programs (as of July 2015)
  • The Veteran’s Administration system that provides care directly to veterans.
  • The Tricare system for active military that also provides care directly; and
  • The Indian Health Service for members of tribal nations that also provides care directly. Members also have access to all of the insurance options available for others (Medicare, Medicaid, CHIP, employer sponsored insurance, marketplace plans and plans in the private market)

We have a complicated private insurance system that now does offer health care as a right to all who qualify or can afford it. The “right” parts are the consumer protections where no one can be turned down because of a pre-existing condition, have a policy cancelled or maxed out, and because certain large employers are mandated to provide insurance. People covered under this “right” are:

  • Those who work for employers with over 100 employees, since January 2015 mandate
  • Those who work for employers with over 50 employees, mandate begins (if still in effect) January 2016
  • Those not covered through work who can afford private insurance without assistance if they are over 400% FPL ($97000, family of four), or between 100-400% if they can afford insurance with subsidies

That leaves out the 126000 in Kansas (Families USA data) who are like the 6.4 million others in states that also have chosen to not yet participate in the ACA supported Medicaid Expansion. Those folks fall between a state’s standing maximum eligibility to qualify for Medicaid (33% in Kansas for parents, 0% for childless adults) and 138% FPL. These folks are too poor to qualify for financial assistance paying for a marketplace insurance plan and too “rich” to qualify for Medicaid in states with very stringent criteria for eligibility.

Therefore, while it is true that things would have been even more difficult for the 80-90% of people in the marketplaces who depend on those tax subsidies to afford those insurance plans had the Supreme Court ruled otherwise in King v Burwell, to say that the SCOTUS decision means that health care is a right is more than a stretch of the implications of that ruling.

Report argues for Medicaid expansion in Kansas

A recent report from the Kansas Center for Economic growth makes the case the expanding Medicaid would be good for Kansas local economies, especially rural communities, and the state as a whole. “Medicaid expansion would go a long way toward increasing economic security for uninsured workers.  It also would be an asset for small businesses—which will benefit from healthier and more productive employees—and the economy as a whole—which will benefit from the flow of federal dollars into the state.” The report details the types of occupations, and the wages in those occupations, where working class people are most likely to be uninsured and eligible for Medicaid if the state chose to expand within new federal guidelines.

The Affordable Care Act was crafted in a way that relied on states expanded their Medicaid programs to cover individuals who made less than 133% of the federal poverty line (138% in actuality when tax deductions were considered).  The federal government is set to pick up 100% of the expenses for 3 years and then 90% thereafter.  The Supreme Court decision of June 2012 made Medicaid expansions voluntary.  Kansas is one of 25 states that has not chosen to expand.



Potential purchases of coverage in the Kansas Health Insurance Exchange: Who is likely in and who not?

The Kansas Health Institute report, “Insurance Exchange will provide many Kansas consumers with new options” estimates numbers for the state as a whole.  While more than 500,000 Kansans may consider purchasing insurance through the Exchange, only

  • 193,000 are most likely since they will qualify for tax credits/premium discounts;
  • 75,000 less likely because they don’t qualify for these;
  • 245,000 whose purchase behavior is unknown depending upon what their employers do; and
  • an additional 43,000 who will qualify for tax credits if Kansas does not expand Medicaid.  This latter population unfortunately will find insurance unaffordable even with the tax credit.

Summary from report:

2014, the Affordable Care Act’s individual mandate will require nearly all U.S. citizens to have health insurance. The health reform law also requires each state to have an online marketplace known as a health insurance exchange where people can obtain insurance.


This new issue brief — the eighth in a series focusing on health reform — examines which Kansans would be most likely to use a health insurance exchange.


Key findings of the brief include:


• More than 500,000 Kansans would have some reason to consider using the health insurance exchange to obtain coverage, though some are more likely to use it than others.


• About 1.7 million Kansans are likely to continue with the coverage they have now.


• The exchange will provide small employers and their workers with more options.


• The exchange will serve as a gateway for determining eligibility for federal tax credits as well as Medicaid and the Children’s Health Insurance Program.”

Five Basic Facts of the Uninsured

This Kaiser Family Foundation issue brief is a good, quick resource to understanding who the uninsured are in America.  Among the most salient points is that most (more than 3/4) of the uninsured live in a family with a worker.  This highlights several issues.

  1. that where you are employed, and the type of job you are able to hold, has always affected the type of insurance and health care you can receive.
  2. this is why ACA tried to encourage more employer sponsored insurance first by requiring insurance coverage of employees by employers of over 50 FTE and second by giving tax incentives for those who employed under 25FTEs.
  3. this is also why ACA put into place a new option for employees who couldn’t find insurance at work…these are the online marketplaces (the Exchanges)
  4. finally, because insurance was still going to be unaffordable for many, especially the working poor and their dependents, the feds were going to help states pay for expanding their Medicaid eligibility criteria to include those who would still be unable to afford private insurance.  KanCare has been pivotal in keeping kids in poor and working class families insured (under 225% of FPL, $4416 monthly income family of 4).