Crowd of African American people in Washington, DC.


In states such as North Carolina that decided not to expand Medicaid under the Affordable Care Act, the percentage of minorities who remain uninsured will be higher than that of whites.

By Brenda Porter-Rockwell

Glenn Scott and her husband, Glenn Jeter, were once both busy working professionals. She was a city planner and he worked at IBM. Scott, who gave up her career to home school their 11-year-old autistic son, is now a part-time mystery shopper. Jeter, 59, was laid off from IBM a few years ago and currently makes $9 an hour as a security guard.

“Now we’re poor. You never feel poor when you have a job. Then one day you realize you are,” Scott said.

The Raleigh residents, previously uninsured, qualified for subsidies on the Health Insurance Marketplace as part of the Affordable Care Act, accepting a silver plan from Coventry Health with a monthly premium of $22.54.

“I felt relieved,” said Scott about securing coverage.

Lydia Griffith, however, does not feel relief. She is among the 377,000 North Carolinians the N.C. Institute of Medicine estimates fall into a coverage gap created when North Carolina did not expand Medicaid as part of the ACA (commonly known as Obamacare). These are people who are not income eligible for government subsidies that would help offset the cost of policies. They’re also not eligible for Medicaid because they don’t fall within North Carolina’s strict coverage rules for adults.

“I don’t feel good about it,” said Griffith, a 57-year-old Fayetteville resident who is single and, like Scott and Jeter, black. “How can you feel good about not having health coverage?”

The nonpartisan Kaiser Family Foundation estimates there are 2.6 million people of color (1.3 million blacks, 1 million Hispanics and 300,000 other minorities) nationwide who will fall into the coverage gap, compared with 2.2 million whites. The ineligibility rates are highest in Southern states, KFF noted.

According to experts, because many minority groups are not qualifying for marketplace insurance, it will be even more difficult to improve public-health outcomes in those populations.

diagram of who falls in the Medicaid coverage gap
In states without Medicaid expansion, millions of adults will not qualify for the program, while still not making enough to qualify for subsidies. Diagram courtesy Kaiser Family Foundation

Addressing health disparities

Public-health experts contend that Medicaid expansion would be a step toward better public-health outcomes, especially in low-income, minority populations. According to KFF, it was estimated that at the end of 2012, the majority of uninsured, non-elderly persons in North Carolina were minorities – 44 percent Hispanic and 21 percent black – compared with 15 percent of whites.

By not expanding Medicaid, “North Carolina has been left out of a major health program,” said Victor Schoenbach, an epidemiology professor at UNC-Chapel Hill. “There is no additional revenue for the state. North Carolina is forgoing millions in revenue and potentially offering fewer jobs in health care than expected.”

Schoenbach said that many who work in public health believe a Medicaid expansion will help outcomes in minority communities. As an example, he pointed to the availability of additional health screenings, which could lead to earlier detection of chronic diseases like diabetes and high blood pressure.

“This offers a little bit of a reduction in stress factors for families. It’s one thing to have an illness, but to have an illness and not know how to pay for care is even more stressful,” Schoenbach said.

The ACA aimed to expand Medicaid coverage to low-income adults and set a national income eligibility level of $15,856 for an individual and $26,951 for a family of three, which translates to 138 percent of the federally designated poverty level.

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Doughnut hole

In North Carolina, Medicaid only covers children in low-income families, the elderly or people with disabilities. Eligibility levels for adults are generally set very low and vary from state to state.

In 2008, the N.C. State Center for Health Statistics and Office of Minority Health and Health Disparities estimated that 21 percent of black families in North Carolina were living below the federal poverty level ($21,834 annual income for a family of four), compared with 6.7 percent of whites.

As part of the Medicaid expansion, the federal government would finance the full cost of expanding the program to everyone under 138 percent of the federal poverty through 2016; after that, the government’s share of the costs would be incrementally reduced to 90 percent in 2020. The expansion was intended to be national, covering low-income individuals, with subsidies for people with higher incomes.

But in June 2012, a U.S. Supreme Court ruling made Medicaid expansion optional for states.

“While the Supreme Court overturned the mandatory Medicaid expansion, the rest of the coverage provisions remained intact,” reads a report prepared by the N.C. Institute of Medicine on the Affordable Care Act. “Children in families with incomes no greater than 200 percent of the federal poverty level (FPL) will continue to be eligible for Medicaid or North Carolina Health Choice, North Carolina’s Child Health Insurance Program (CHIP).”

But in many cases, their parents would not qualify for Medicaid as intended by the ACA.

As of the beginning of March, 390,925 individuals in North Carolina were determined eligible for the online federal insurance exchange, according to the Kaiser Family Foundation. Of that number, 251,953 were eligible for subsidies, while 5,691 were eligible for Medicaid.

About 200,546 individuals had already selected a plan by that date. Final numbers for how many people purchased insurance on the exchange are due in late April.[/box]

Griffith falls below the poverty line. She works 12 hours a week at a local church, making only about $9,000 a year. She has been at her job for 12 years and had worked 20 hours a week before her hours were cut a few months ago.

Although black Americans have the same or lower rate of high cholesterol as their non-Hispanic white counterparts, they are more likely to have high blood pressure, another ailment both Scott and Griffith are attempting to manage.

Griffith said she manages her high blood pressure by visiting a community health center run by the Cumberland County Department of Social Services. Each visit costs her $130.

“Right now, my options for my own doctor are limited. Not that the doctors at the center aren’t good, but I would like to be able to pick out my own doctor,” she said.

Glenn Scott has been managing her high blood pressure for years, as well as diabetes. Those ailments, along with cardiovascular disease, are three of the top diagnoses affecting black Americans at a greater frequency than whites. According to the U.S. Department of Health and Human Services, blacks are twice as likely to be diagnosed with diabetes as non-Hispanic whites.

In addition, blacks are more likely to suffer complications from diabetes, such as end-stage renal disease and lower-extremity amputations.

bar graph showing higher numbers of minorities uncovered without Medicaid expansion
More racial and ethnic minorities will remain uncovered in states that chose not to expand Medicaid under the Affordable Care Act. Graph courtesy Kaiser Family Foundation

“The [ACA] is a win-win for our patients to finally get access to affordable health insurance,” said Janice Collins-McNeil, a nursing professor at Winston Salem State University.

“What is very important to note is that what is covered under this act is a strong emphasis on preventive-care services for those leading health indicators that disproportionately affect black people,” said Collins-McNeil, who also works in private practice in Charlotte.

Most health plans under the ACA must cover a set of preventive services like shots and screening tests at no cost.

Denise Chantal Howard, a nurse practitioner, said she sees a high percentage of minority patients who are affected by the absence of Medicaid expansion. She’s a full-time practitioner in a low-cost community health clinic for the uninsured in Charlotte and an adjunct clinical faculty member at Winston-Salem State University.

According to Howard, 43 percent, or 800 of 1,400, of the patients at the clinic fall into the coverage gap.

“What that means for us is that we will continue to provide continuity of care, but those patients may not have access to specialist referrals if needed, certain diagnostic tests or surgeries,” Howard said.

Income levels

For some, securing a health plan has taken more than one pass on the exchange.

Madison Hardee, a health navigator and staff attorney at Legal Services of Southern Piedmont in Charlotte, said she recently met with a woman who needed extra help after starting an online marketplace application.

The woman’s income-verification documentation indicated that she earned about $10,000 annually. That was too little to receive a subsidy and she didn’t qualify for Medicaid. The plan options offered to her were unaffordable.

“So we had a conversation about other sources of income she may have. She told me she did some babysitting from time to time and that she also braids hair,” Hardee explained. “We were able to count that as income, which put her over the poverty line and made her eligible for marketplace coverage with substantial financial assistance.”

But others, Hardee said, will go without health insurance as a result of falling into the coverage gap.

“Those are the hardest cases for us as navigators,” she said. “There’s always going to be some people who even when we look at their entire income, they cannot get over the poverty line.”

For those cases, she said, they’ll provide a referral to a free clinic and tell them that if their income rises above the poverty line they’ll be eligible for a special-enrollment period and a subsidy.

‘Pay now or pay later’

Of the 19 states that did not expand Medicaid, about five are said to be reconsidering that decision in time for the new enrollment dates in November. North Carolina is not among those states having that conversation. And that, some public-health experts have said, is a mistake.

“Essentially, it’s a matter of do we pay now or pay later?” Howard said. “Do we want to invest in preventive care and detection or have hospitals go bankrupt because of unpaid bills that patients with catastrophic illness cannot afford to pay?”

Added Schoenbach: “This decision puts pressure on institutions who won’t get the Medicaid money. Some providers have a disproportionate amount of Medicaid patients and rely on Medicaid billing, which they’re not getting.”

“I’d say we pay for preventive care now rather than later,” said Collins-McNeil.

While the official enrollment period for health care coverage for 2014 has ended, there is no deadline for eligible people to enroll in Medicaid.

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Brenda Porter-Rockwell

Brenda Porter-Rockwell's experience spans more than a decade of writing, reporting and managing publications (for- and non-profit businesses and public relations agencies) on topics ranging from local...

6 replies on “Minorities More Likely to Fall Into ACA Coverage Gap”

  1. While this piece does address the many deficits & desperate needs of many, especially Minorities. It doesn’t do justice to the entire Needy population of N.C. There are also PLENTY of Non-Minorities that are also being ignored & left by the wayside by these insane actions of the MC Legislature & Repub. Governor.
    Case in point, my best friend has among several other major Disabilities, a TERMINAL Heart Condition, Diabetes, can barely walk & cannot sit or stand for more than a few mins. at a time. He has been in a “dogfight” with the S.S.A. for approx. FOUR YEARS, attempting to receive Disability Benefits, which he worked & paid for, for over 42 yrs. Only to be denied time & again, according to THEIR OWN WORDS, because these idiots seem to claim that he “can work at some type of job”. “They clearly state that they do not know of what type of job that he could possibly hold or attend sufficiently, to keep it, or that regardless of it being even a Part Time 10-20 hr. a week position, that he can do so & somehow support himself with that income.” Of course in NC, that along with the Blockage of the Medicaid Expansion, disqualifies him from getting ANY Health Benefits. he also has Medicine costs running at approx. $2200-$2400 a month, for what is needed to simply keep him alive & not suffering 24-7. If it were not for the Cheap/Sub Par Care at a local County Medical Clinic, aid from the National Heart Assoc., the MAPP Program & ONE caring compassionate Cardiologist that has donated his treatment to stay alive, my friend would already be DEAD. But, due to the actions of NC, he cannot get Medicaid or Medical/Prescription Assistance & will most likely die before the S.S.A. approves him for honest Disability Benefits. Of which, after he starts to receive those benefits, he will be required to pay the entire amount in return, in MEDICARE Parts A & B Coverage & still will not be able to get his needed Medication, eat or keep a roof over his head, short of a Homeless Shelter or Nursing Home. This is simply because of the fact that all of those years that he DID work & was a productive member of society, he made too much income in the past, to qualify him for Medicaid instead. There is a SEVERE problem with elected officials that have ZERO compassion for the Disabled, Needy, Indigent & Dying, in this state. And absolutely NO desire on their part, to address or even consider any changes in position. Yet, SOMEHOW, the so-called Conservatives seem to believe in their strange “Christian reasoning”, that this is Spiritual behavior.

    1. KJ – My heart breaks when I read your post. I have a brother and sister-in-law in NC that are in the same boat as your friend and I am angry beyond words about it. That said, I would ask that you don’t lay the blame at the feet of Christians…..the blame rests with Obama and his lies and with his devoted minions who crafted this horrific travesty to start with and/or re-elected him for a second term. If he had been stopped at a single term, we could have overcome this through legal challenges and repeal processes. God has nothing to do with this KJ…nor do His real followers. God bless you….and God be close to your friend and his family.

      1. I am moved by KJ’s friendship and concern for her/his
        friend. This friend has endured abhorrent unjust responses to his plea for
        help. It is clear that he is experiencing immeasurable emotional pain caused by
        the personal, intimate betrayal of his worthiness to live– The physiologic
        equivalent is gasping for air and panicking when it is not forthcoming.
        (Since he is already living and breathing, there are no Republican lawmakers on
        a rabid mission to enact existing laws to assure his rights to access medical

        “Wiser Now’s” response was to advise KJ to be angry at the President. Then she
        stated that if he were not the President there would be no increased access to
        healthcare for many people, and that the SSA under President Romney would
        handle his case differently….oh, and God loves you and cares….Really?OK,…

        My wager is that “Wiser’s” comment was interpreted as, “Your situation is
        sad, but Christians did not refuse to help you in this time of great need (but
        they did). It is President Obama’s fault because he was able to implement what
        is already a right in every other industrialized nation on the
        planet-(eventually)healthcare coverage for every American. The Republicans hate
        the President and every thing he has tried to do, and I have been scared
        witless by those I deem to be authority figures. And because the authority
        figures pray loudly and publicly, they are “real Christians”.
        Therefore, I will hate the President, and I belong to the Republican Party. The
        Republican Party is the Christan Party of “Real Americans” and tends
        to offend, exclude, and delegitimize most groups of people who are not white,
        Protestant, financially stable, straight,and male. I will believe every false
        claim that they made about the ACA. I will not bother to actually research the
        Congressional records and review a broad range of information sources.
        I know that the whole healthcare plan is a Republican
        creation, and it promotes the Republican value: individual responsibility… Newt
        Gingrich even complained to Hillary Clinton in the 1990’s that her plan did NOT
        have an individual mandate. Isn’t that ironic? Health care coverage means that
        small hospitals do not fail financially and close completely and people lose
        their jobs due to providing care for uninsured people, But…none of that
        matters…because…we, in the collective, hate President
        Obama, and it really doesn’t matter to me that your friend is suffering

        KJ–the fact that we live in a nation of such wealth and
        resources belies the reality for so many people, including your friend. We have
        the best of everything, and it comes down to factors including who you are, how
        much money you have, your employment, the family into which you were born, the
        address where you live, and hopefully some luck or two shiny pennies to rub
        together that all coalesce to determine whether or not you are a human being
        worthy of having health care. Is that what Republicans call “American
        Exceptionalism”? KJ- I am angry about what your friend has been denied and I share your anger at the elected lawmakers who, in
        some case, are sure to “pray loudly on the street corner” as if that
        insulates them from their responsibilities and the tragic outcomes of their
        decisions which cause undue harm to the most vulnerable citizens they are paid to
        represent. It is criminal; research from Harvard demonstrates that higher rates
        of insured people significantly decreases morbidity and mortality in a
        population. The lawmakers
        who refuse to act humanely, and fail to uphold their responsibility for the
        General Welfare (refer to The Constitution of the United States-most
        Republicans carry a pocket-sized transcript with them everywhere), are at least
        somewhat culpable for peoples’ adverse health consequences which could have been treated
        if Medicaid were expanded.

        The Republican position on the healthcare law is like the position they have on
        every other issue–they are WRONG, anti-American, and every decision they make
        these days is infused with hate of the President and the people who voted for
        him, and reverence to THEIR almighty god…the market”

        If you haven’t tried local or regional programs or advocacy groups that have
        resources/information for people who have disabilities, you might try them.
        Maybe the local department of aging. Perhaps a hospital social worker when he
        is admitted. Some pharmaceutical companies will help pay for RX. My family is
        from NC. I honestly am thankful that my grandmother is not alive to see it. She
        was so proud of her state, and she helped
        to raise money to establish the Battleship Memorial in Wilmington. She used to
        have some choice names for Jesse Helms, whom, your legislature would exhume, if
        possible. It is so painful to watch that beautiful state be harmed by
        a minority of people who are well funded. The legislature making it so hard to
        vote is a criminal operation with the blessings of the few who bought and paid
        for it.

        Lastly, I am not convinced that the Christians who deprive people of human
        rights and human dignity and constitutional rights are following the real
        Christ. Unspeakable injustice is being hung on the yoke that the vulnerable
        must carry. Vote them out for the sake of health and welfare and education and
        general prosperity in NC.

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