Who’s not eligible?

The start of the federal health care insurance program on Oct. 1 was preceded by a heavy wave of advance news coverage to tell the U.S. citizenry how the system will work. The reporting informed readers and listeners who could use the system and how to use it.

But there was one big hole in all this journalism.

Most news stories described who is eligible and why. None described who is not eligible and why.

Wouldn’t potential customers want a list of what made them ineligible before they went shopping and were embarrassed by being rejected?

The assumption seemed to be that we were supposed to read who was eligible and extrapolate from there—that whoever wasn’t deemed eligible, was therefore ineligible. But no one came out and said that, and assumptions are hazardous. Numerous stories reported that a little more than half of the uninsured would be covered by the ACA, which certainly seemed to indicate that nearly half could not be covered by it, but reporters showed a stunning lack of curiosity about why that remaining near-half of the uninsured were by implication not eligible. In Nevada, there are an estimated 577,000 uninsured residents. The national program is expected to cover up to 311,000.

Does the law simply address those who are eligible and remain silent on everyone else, thus rendering them ineligible by default? That seems like a poor way of doing business. And finding out the answer during a national government shutdown proved difficult. So we turned to our colleagues around the country. Surely someone had published, broadcast or posted a list of things that disqualified 266,000 Nevadans.

For one thing, there were plenty of journalists who were reporting that the new national program does not cover everyone:

• “Why Some Midlands Residents Won’t Be Covered Under the ACA”

• “Affordable Care Act May Not Cover Alaskans Most In Need of Health Insurance”

• “Obamacare to leave 31 million uninsured”

• “Obamacare Won’t Cover Everyone”

• “Obamacare leaves millions uninsured. Here’s who they are.”

That seems to suggest that information on who is excluded from the program needs some attention.

That last headline was in the Washington Post and sounded like just what we wanted. But when we checked it out, it was a spinoff of a report at HealthAffairs.org that simply gave a demographic profile of those who will not be covered by the federal program, by race, employment status, age, income. But the reports never said who these people are or what makes them ineligible, if they are ineligible.

If they’re ineligible because of those demographics, neither the Post or the Health Affairs pieces say so.

Are all native-born left-handed men with limps ineligible? If so, why? What guidelines are in the law that exclude some people from coverage?

We needed someone familiar with the language of that law. With government out of reach, we turned to a different kind of expert. At the suggestion of Trudy Lieberman of the Columbia Journalism Review, we sought out Washington and Lee University law professor Timothy Jost, one of the leading experts on the health care law. (As this is written, there are 41 articles on the Google news page that use interviews with Jost.)

Jost returned our call while waiting to board a plane. We put our question to him.

Jost: “Well, everybody whose income’s below 138 percent of poverty was supposed to be eligible for Medicaid until the Supreme Court … decided otherwise. Now, in about half the states, every person who is legally present in the country and not incarcerated is eligible for Medicaid. Actually, also—see, this is where it gets complicated—people who are legally present but have been so for less than five years are not eligible. But anyway, most people who are below 138 percent of poverty are eligible for Medicaid in states that expanded [their Medicaid programs]. And states that didn’t expand, the people below 100 percent of poverty who are not otherwise already eligible for Medicaid would not be covered. That would include single adults, and it would include couples without children. And it would probably include a lot of parents. In Virginia, if your income’s below 30-some percent of poverty, you’re not eligible for Medicaid even if you’re a parent. So those people are not eligible for anything.

“People between 100 and 400 percent of poverty who are legally present in the United States and not incarcerated or citizens, are eligible for advanced premium tax credits unless they have coverage through their employer or are offered coverage through their employer or unless they’re eligible for some government program. Those are probably the main exceptions. People above 400 percent of poverty can certainly buy health insurance. They can buy it through the exchanges, but they’re not eligible for any assistance. …

“Basically people aren’t eligible for premium tax credits if their income’s above 400 percent of poverty, they’re below 100 percent of poverty, or they’re eligible for a government program or they’re eligible for affordable and adequate employer coverage. That’s, I guess, who is not eligible.”

It’s difficult to believe that one of the lessons that was supposed to come out of the abortive 1990s Clinton health plan was a new program that was easy to understand.

Jost said it is difficult to account for why nearly a half of all uninsured will remain ineligible for the national program—46 percent of those currently uninsured, in Nevada’s case. He was able to name several categories of people, but they did not seem to account for so many people being excluded from the new system. He mentioned illegal aliens—certainly a factor in Nevada’s service economy—plus people who choose to remain uninsured, are confused, have been misled, or are between jobs.

“But I doubt that’s 46 percent of the population,” he said.

Of those who will still be without insurance once the federal program is operating, about 80 percent are expected to be U.S. citizens.

The Congressional Budget Office predicts that after the law is fully operational, 7 million people will be dropped from their employer health plans, and 5 million people will shift out of private plans, all of this to happen within five years.

As the ACA is coming on line, some employers are dumping all but a minimal commitment to health insurance. Trader Joe’s announced a plan to give each of their employees $500 a year. They will then be cut loose to find their own best deal.

UPS had already announced plans to dump some workers’ spouses from the corporation’s health insurance. It was joining numerous other corporations who had already done so.

In California, state legislators are considering creating an employer-funded trust to cover uninsured who remain after the federal program.