Supreme Court's ACA ruling could mean an expansion of vulnerability

Not all of those who gain insurance under the healthcare reform law will stay insured if Florida and other states decide to forgo a Medicaid expansion by 2014, as I reported last week.

So what does it mean to be insured only part-time? Unsurprisingly, research suggests it means less access to primary care and more medical debt that hospitals, doctors and households hope to see reduced by the reform law.

Those who end up insured part of the time were less likely than those insured nonstop to see a regular doctor, get their blood pressure checked or undergo routine cancer screening, a Commonwealth Fund survey found.

Another Commonwealth Fund survey of young adults found the sporadically insured were more likely to report struggles with medical bills and debt, such as problems with paying their medical bills.

The Affordable Care Act allows states to expand Medicaid by 2014 to include those who earn up to 133% of the federal poverty level. An estimated 15 million could gain Medicaid coverage under the law by 2019, based on conservative projections by the Kaiser Family Foundation.

For households with income above 100% but below 400% of the federal poverty level, the law offers subsidies to buy commercial health plans.

These two provisions of the law, combined with new rules for insurers, are central to the law's goal of reducing the number of uninsured.

But last week's Supreme Court decision on the ACA raises doubts about whether states will expand Medicaid. The court said states won't risk losing existing Medicaid funds should they fail to open the safety net to more people, removing a powerful incentive to do so. Some governors quickly responded to the decision with a suggestion they would forgo expansion.

Florida Gov. Rick Scott said outright that he won't expand Medicaid.

That will leave adults too poor to earn subsides for commercial health plans (with income at or above the federal poverty level up to 400%) without insurance if they earn too much to qualify under existing Medicaid criteria, which varies from state to state.

In Florida, that includes any adult who does not have children and who is not pregnant, the Kaiser Family Foundation reports (PDF). It also includes any working Florida parent who earns more than $13,369 for a family of four, or a household income of 58% of the federal poverty line.

And some adults left out of the expansion will skirt the line of eligibility for health plan subsidies available under the law. A change in jobs or work schedules can shrink or increase household income—and tug an adult above or below the eligibility threshold for subsidies. An adult who earns more than the poverty threshold will qualify for subsidized benefits. But the insured who slip below poverty as work income fluctuates may be left uninsured in states that do not expand Medicaid where eligibility is already limited, such as Florida.

You can follow Melanie Evans on Twitter: @MHmevans.