While the Affordable Care Act (ACA) will have a profound effect on free clinics, many people living in America will be left uninsured even after the act is fully implemented. According to Professor Timothy Jost of Washington & Lee University School of Law, one of the most important categories left uninsured will be Americans covered by Medicaid who will lose coverage because of the recent Supreme Court decision. Uninsured adults falling at or below 138% of the Federal Poverty Level were supposed to qualify for Medicaid under the ACA. However, the Supreme Court decision allows states to opt out of this requirement and keep their existing Medicaid eligibility categories.
The Congressional Budget Office (CBO) estimates that because of the Supreme Court decision and states opting not to expand Medicaid, six million fewer will be covered by Medicaid, half of whom will go to the exchanges and half of who will be uninsured. Under the ACA, Medicaid and CHIP eligibility determinations will be greatly simplified. However, those eligible will continue to face many barriers to getting enrolled, and some may choose not to enroll.
Professor Jost stated that the next big category of individuals to be left behind is the undocumented, who will constitute about a quarter of the uninsured. They will not be eligible for advance premium tax credits, for Medicaid or CHIP, and will not be eligible to purchase private insurance with their own money through the exchange.
Another big category of uninsured will be people who are not subject to the individual mandate. Anyone who cannot purchase a bronze policy in the individual market, through the exchange, or through an employer, for 8% or less of household income is not subject to the mandate. Persons with incomes between 100 and 250 percent of poverty will be eligible for premium tax credits that will make insurance affordable, and will thus be subject to the mandate. The CBO estimates that about 18 to 19 million Americans will be exempt from the mandate.
There will also be those who are subject to the mandate but who, for whatever reason, remain uninsured. This may be particularly true in the first couple of years when the mandate penalty is very low at $95 for the first year. According to CBO estimates, about six million Americans, including dependents, will forgo insurance and pay the penalty.
Free clinics will also be needed to provide care to those who are insured but cannot find or afford providers. For example, some persons eligible for Medicaid or for insurance through the exchanges may be unable to afford the cost-sharing that they will incur under Medicaid or under ACA private insurance coverage.
We face an exciting and challenging year, according to Professor Jost. He agrees that while much remains uncertain, one thing is sure, the poor will always be with us and for the foreseeable future they will need free clinics.
-article based on presentation by Professor Timothy Jost, Washington & Lee University School of Law