One of the most hotly debated issues in health care for several years has been Virginia’s refusal to expand its Medicaid program, which would allow more working families to have access to health care. As a result of this inaction, hundreds of thousands of low-income adults fall into a coverage gap. With income below the poverty line, they are too poor to qualify for subsidized insurance from the federal Marketplace, but they make too much money to qualify for Virginia’s current Medicaid program.
If Virginia lawmakers close this coverage gap, nearly 400,000 Virginians across the Commonwealth could get access to quality, affordable health insurance.This book explains how people fall into the coverage gap and tells the stories of a few of them.
Table of Contents
- Childless Adults
- Low-Income Parents
- Children and Young Adults Who Age-Out of Medicaid
- People Waiting for a Disability Determination
- Disabled People Waiting for Medicare
- Older Virginians
Virginia’s current Medicaid program does not offer full coverage to adults unless they are:
- parents (with children under age 18 living with them)
- over 65
Adults who do not fit into one of the above categories are ineligible for Medicaid. It does not matter how poor the adult is – there’s simply no coverage.
Jesse lives in Orange, Virginia. He’s a minister who has worked in a variety of jobs over the years. He is 57. He used to have health insurance through his or his wife’s employment. But, in 2011, his wife passed away, and he lost his job when his company closed. As a result, he lost his employer-based health insurance.
Unfortunately, Jesse suffers from chronic blood clots, which require daily medication, and monthly tests. When he lost his insurance, he wasn’t able to get the treatment he needed. He developed extremely painful ulcers in his feet and legs.
Over time, his condition worsened until it was so bad leg amputation was considered. Emergency room doctors at Mary Washington Hospital in Fredericksburg were able to stabilize him and avoid surgery. He now works part-time for a local human services agency and earns only about $800 per month. As a “childless adult,” he does not qualify for Medicaid, and his income is too low for federal tax credits to buy private insurance. “If it wasn’t for the free clinic, I’d be up a creek,” he says.
Current Medicaid eligibility for parents in Virginia is very restrictive. The income eligibility level for parents depends on where the family lives, but is shockingly low everywhere. For example, working parents in a family of 4 must have income that is:
- Under $12,372 per year if they live in Northern Virginia
- Under $9,516 per year if they live in Richmond, Norfolk, Roanoke, and other urban areas
- Under $8,136 per year if they live in Bristol, Danville, Suffolk, Stafford county and other rural areas of Virginia
Because of these austere eligibility levels, parents often remain uninsured even though their children qualify for Medicaid.
Melyssa and her three young sons live near Culpeper. Her husband worked as a welder and had health insurance for the entire family through his job. She’s 33. But the family’s world changed in September 2014, when her husband died suddenly. They were devastated, abruptly left without a husband, father, provider – and health insurance.
Friends and community members stepped up to help her pay bills and keep the family home. Melyssa gets some Social Security and works part-time while studying for a nursing degree. But her monthly income is $300 over Medicaid limits for parents. The children qualify for Medicaid, but not Melyssa. And her income is not enough to qualify for tax credits to help buy health insurance from the federal marketplace. When Melyssa realized she fell into the healthcare coverage gap, she said, “the system is very, very flawed. It doesn’t help people who need it. I’m very worried about being uninsured. I had thyroid cancer before, and I still have to take medication that costs me $120 per month – I can’t afford it. I had no idea it would be so hard to get health insurance.”
While she struggles to keep her young family afloat, unexpected expenses are a problem. Last July she had to go to a hospital emergency room for severe abdominal pain that turned out to be ovarian cysts. That visit cost $4,000, a bill she still owes but can’t pay.
Virginia’s Medicaid program provides comprehensive health coverage to children under age 19. The Medicaid income level for children in a family of 4 is $36,408 per year. The FAMIS program covers higher income children with family income up to $50,430 per year for a family of 4. When children turn 19, their Medicaid coverage stops, unless they are disabled, in foster care or adoption assistance. Even though their health coverage stops, their need for health care doesn’t.
Zac Talley is nineteen years old. He’s a high school senior, living with his father and 13-year old sister in Chesterfield County. When Zac was 2 years old, he was diagnosed with leukemia and required treatments for many years.
He still goes to VCU’s clinic for cancer survivors. He has other health problems including diabetes, several serious orthopedic conditions, and some mental health challenges. He had health insurance through Medicaid, but it was terminated when he turned 19.
He plans to finish high school and wants to work as a chef or auto technician. But, without insurance, he doesn’t know how he’ll get all the health services he needs. His family lives on a very tight budget, and Zac’s diabetic test strips alone cost $180 per month.
Zac said, “It doesn’t make sense to stop Medicaid when kids turn 19, especially if they’re sick or still in school. It’s like they’re saying ‘Good luck with your life. We don’t care if you die!’”
Virginia Medicaid provides coverage to people who are declared “disabled” according to the criteria established by the Social Security Administration. The process for disability determinations can take months or years – even for people who are very sick.
That’s because the system is overwhelmed, and there are several levels of possible appeals. The disability criteria also are very strict and require the medical condition to be expected to last a full 12 months or result in death. Sometimes, when an illness first strikes, it’s hard to know how serious it is and how long it will last.
Heather lives in Midlothian, just south of Richmond. She worked for many years as a district manager for large retail businesses, often traveling for her work. She always had health insurance at her jobs, but became unemployed and uninsured after the company downsized in 2013. She then took a job as a crew trainer and manager at a food franchise. Even though she felt a lump and pain in her breast, she tried to postpone a screening until her new health insurance kicked in after her work-related probationary period. But in January 2015, before she qualified for health insurance at her new job, she was diagnosed with triple negative breast cancer with genetic mutations, an aggressive form of breast cancer.
Heather tried to work while starting cancer treatments at VCU Medical Center, but the pain and side effects of chemotherapy made work impossible. In March, she quit her job to concentrate on her health and cancer treatments. But this left her without income and without health insurance. She immediately applied for disability benefits. Social Security denied her claim. She has appealed the denial and is still waiting for a hearing.
Facing enormous bills for health services along with ongoing living expenses, Heather became totally dependent on charity care from VCU and help from her neighbors and friends. She had to abandon her home and move in with a friend.
“I know another cancer patient who is living in a box behind a grocery store, and she walks to her chemo treatments,” she said. “If not for my friends, I’d be in a box, too. There are terrible stories out there. I already owe over $350,000 in medical bills. I’m still in treatment with more bills accumulating. I’ll have to file bankruptcy.”
She understands that Virginia lawmakers decided not to provide Medicaid to adults like her and her 20-year old daughter.
“I don’t know how the state can do this to people. It breaks my heart. I have lost everything – my car, my home. I have bills coming out my ears. My credit used to be good; now it’s horrible. Although I will live, financially I’m ruined. If I had Medicaid when I got sick, I’d still have reasonably good credit.”
Medicare health insurance is available to most people who:
- Are over age 65
- Have been entitled to Social Security Disability (or Railroad Retirement) benefits for 24 months
- Have Lou Gehrig’s Disease (ALS) or end-stage renal disease
Disabled people waiting for Medicare can sometimes get Medicaid. Their income must be below 80% of the federal poverty line ($9,888 per year), and they must also have less than $2,000 in countable resources, like bank accounts. If their income is higher, they can get Medicaid by meeting a “spenddown” every six months. This requires substantial medical expenses or medical debt. This part of the Medicaid program generally works only for people with catastrophic medical costs.
Sarah Woodruff and her disabled husband are both 44.They live in Castlewood with their 9-year old son. Their son has Medicaid, but Sarah and her husband don’t. They lost their Medicaid coverage in 2014 when Mr. Woodruff began receiving Social Security Disability benefits of $1,200 each month. As a disabled person, Mr. Woodruff can get Medicaid through the spend-down program, but only if he has $4,700 in medical bills or medical debt. Without any health insurance, he’s reluctant to see a neurologist for his seizures and run up other medical bills.Meanwhile, both he and Sarah are stuck in the coverage gap. Mr. Woodruff ’s two years in the gap will end in May when his waiting period is over and he can qualify for Medicare. But not Sarah. She’ll still be stuck in the gap.
There are 43,300 adults aged 50 to 64 who are uninsured, but they don’t qualify for Medicaid, Medicare, or Marketplace coverage. They are stuck in Virginia’s coverage gap. They may have chronic health conditions which aren’t serious enough to qualify for disability – but they still need medical services, screenings, and prescriptions. Their medical conditions can worsen dramatically – or remain unknown – if they can’t get necessary health services and screenings.
Sherrie Sauer is a 60-year old lab technician. She has custody of her granddaughter (age 9) and grandson (age 10) who have lived with her for most of their lives. Because of the responsibilities of caring for the children, she works part-time, earning about $12,000 per year.
Fortunately, the children have Medicaid, but Sherrie is uninsured. She has too much income to qualify for Medicaid herself, but not enough to get affordable Marketplace insurance. And she’s too young to qualify for Medicare since she’s not 65. The Medicaid limit for caretaker relatives and parents in Hanover County is only $6,672 per year for a 3-person family. But she’d need at least $20,100 per year to qualify for Marketplace insurance with tax credits. Her income leaves her in the coverage gap.
Without insurance, she hasn’t seen a doctor in nine years, but she has various health problems that she fears are getting worse. “I’ve worked for forty years, paid my taxes, and I’m raising my grandchildren on my own,” she says. “I struggle to pay our bills and worry about my health. It’s disgraceful that there’s no help for me now that I need it.”