(Bloomberg) — Amber Sanchez, a San Francisco cancer survivor, skipped visiting the gynecologist last year to check a growth on her ovary because she was uninsured. This year, it's at the top of her New Year's plans.
The difference: As of Jan. 1, the 27-year-old is eligible for California's Medicaid expansion under the Patient Protection and Affordable Care Act (PPACA).
In Alabama, which rejected the expansion, Jefferica Poindexter isn't so lucky. Dealing with high cholesterol, chronic sinus pain and a bad back, she depends on emergency rooms and nonprofit clinics — when they can see her.
"I've tried to go the clinic," said Poindexter, who is 63. "They're already booked by the time they get to me."
The women's fates are the consequence of a political debate over "Obamacare" that's divided the United States roughly along party lines: Democratic-led states have expanded Medicaid programs for the poor under PPACA; most Republicans have refused.
While the law's online exchanges draw more scrutiny, it's Medicaid that may determine the health of millions of Americans. The expansion is one of the twin pillars created by the law to supply medical care to the nation's uninsured, complementing subsidies for private insurance.
Still, with only 25 states choosing to participate in the expansion, almost 5 million people will be left out, according to the Kaiser Family Foundation, which studies health policy.
Real people
"These are real people with real health care needs who may work but don't have a lot of income, and no way to be able to afford health insurance," said Kathleen Stoll, health policy director at Washington-based consumer group Families USA.
About 2.1 million people enrolled in private medical plans through PPACA last year, as its online insurance markets rebounded from software flaws that hobbled their debut in October. About 3.9 million more people were newly enrolled in Medicaid through November, according to a Dec. 20 report from the U.S. Department of Health and Human Services.
Medicaid sign-ups may have been higher if 25 states, mostly Republican-led ones in the south, hadn't been able to opt out of the expansion. A 2012 Supreme Court decision upheld their right to refuse. The Obama administration is trying to persuade more Republicans to follow the lead of Arkansas and Iowa, which expanded Medicaid using private insurance plans, David Simas, a White House deputy senior adviser, said Jan. 2.
Election advantage
The Medicaid fight offers hope for Democrats whose 2014 election chances took a hit from the embarrassing October rollout of the insurance exchanges, said Ed Rendell, the former Pennsylvania governor and ex-chairman of the Democratic National Committee. In states like Florida and Pennsylvania, Medicaid may make a difference in governor's races, he said.
"You're telling people who don't have health care now that you can give it to them, and that's something that can get people off their duffs and turn out the vote," Rendell said in a telephone interview.
PPACA replaced a patchwork of state eligibility requirements that typically excluded childless adults from Medicaid. The 2010 law opened the program to anyone making less than 138 percent of the federal poverty level, about $16,000 for an individual.
Medicaid's critics say the program discourages work and provides substandard care. They say states can't afford expansion, even if the law requires the federal government to cover at least 90 percent of costs for new enrollees.
$710 billion
"We're having a desperate struggle to pay for those on the rolls now, and to add several hundred thousand, the money's not there," said Alabama Representative Jim McClendon, the Republican chairman of the state House's health committee. "It's just that simple."
PPACA is expected to add about 13 million people to Medicaid over the next decade, at a cost of $710 billion, according to the Congressional Budget Office. Among those not covered in states opting out, about half are black and Hispanic and half white, according to a study last month by a Menlo Park, California-based Kaiser. Seventy-nine percent live in the south.
Poindexter, the Alabama woman, said she's biding her time for now. She said she hopes to avoid serious illness for the next two years, until she's old enough for the federal Medicare program for the elderly.
When a doctor prescribed medication last year to control her cholesterol, Poindexter refused because of the cost. She also decided against a colonoscopy a physician recommended.
"I'll make it to Medicare and get it done then," she said in an interview last month in her Birmingham home.
Hospital bills
Poindexter said she's been unemployed since 2009 when she left her home-health job, after developing chronic back pain from a pinched nerve. She receives $731 a month from Social Security, and already has $750 in unpaid hospital bills she can't afford, she said.
The Birmingham woman tried to enroll for health insurance in December and learned she falls into the law's new coverage gap: She makes too much for Alabama's more-restrictive Medicaid program, which covers families making less than $111 a month, and too little to qualify for the federal law's private- insurance subsidies, which kick in only above the Medicaid limit of 138 percent of poverty.
