Long excluded by Medicaid programs in most states, millions of low-income adults without children could qualify for coverage under Democratic health overhaul proposals.
Marilyn Matthews has no job, no health insurance, and until now, no chance of qualifying for Medicaid.
She's unquestionably poor — her last regular paycheck was more than three years ago — and would meet the income criteria for Medicaid. The rub is that Matthews, 51, is a healthy adult with no children.
While Medicaid is the main government health insurance plan for the poor, the joint state-federal program has excluded Matthews and millions of other adults with no dependent children since the 1960s. Medicaid has been limited mainly to children in poor families, the elderly, pregnant women and the disabled. Some states have tried to fill the gap, but childless adults now comprise a majority of uninsured Americans.
The lowest-income members of the group would be among the big beneficiaries of the Democratic health insurance overhaul plans in Washington.
Senate legislation and President Obama's new health proposal would expand eligibility to all with incomes up to 133 percent of the federal poverty level, or $14,404 for a single person. The House bill would set the mark at 150 percent or $16,245 for single people.
Over 10 years, Medicaid enrollment would grow by 15 million, including not only childless adults but others whose incomes don't qualify now for the program.
Whether the Democrats can push an ambitious plan through Congress is uncertain. If one doesn't pass, the states are in no position to expand Medicaid coverage without federal help: the states face huge shortfalls from the recession.
Covering childless adults would mark a radical shift in thinking about who deserves a helping hand, not to mention a departure from what Congress intended when it created Medicaid 45 years ago.
The exclusion is rooted in the welfare system of 17th Century England, and an attitude that able-bodied men should not be on the public dole. Imported to America, the distinction was reflected in cash assistance laws enacted during the New Deal, which served as a blueprint for Medicaid years later.
Pros And Cons
Supporters of a Democratic overhaul say excluding childless adults is an anachronism at a time when they are just as apt to become ill or face crushing medical expenses as anyone else. Even for many working adults, they note, health insurance has become unaffordable in recent years.
Critics say expanding Medicaid twists the program's original intent, which was to aid the most vulnerable citizens. They also cite the budget-busting potential of expanded public health care.
But there is ambivalence on both sides. Conservative critics have backed off some of the strident anti-welfare rhetoric that has colored such debates in the past. And some supporters of expanded public coverage for the poor question whether Medicaid is the right vehicle, because care can be uneven, and the program carries the moral stigma of welfare.
"It is great that all these people will be able to get care. I don't want to denigrate that. But it is perpetuating this two-track health care delivery system," says Penn professor Michael Katz, author of "The Undeserving Poor: From the War on Poverty to the War on Welfare."
Many doctors already refuse to accept Medicaid patients because the government payments are so low. In a survey of major cities last year by health consultants Merritt Hawkins & Associates, Philadelphia ranked near the bottom in the percentage of cardiologists and OB/GYNs who accepted Medicaid.
Administrative hassles may also limit care. A 2008 study in the journal Health Affairs found that Pennsylvania took the longest to pay doctors for Medicaid services – almost four months, on average, further discouraging participation.
Supporters say just a fraction of the uninsured would have trouble getting adequate care while millions would benefit from the expansion. Moreover, they say, at a time when many uninsured visit expensive hospital emergency rooms as their primary source of care, expanding a program like Medicaid, with its emphasis on preventive care, is more efficient.
Many Need Care
What is clear is that an expanded Medicaid would cover a wide range of people, from uninsured young adults to empty nesters to divorced spouses and widows left without insurance.
Many of these folks have un-met health needs. The number of people on Medicaid who have severe mental illness and substance abuse addictions is expected to more than double if the overhaul passes.
The legislation would also bridge a gap for unemployed and uninsured Americans who are not old enough to qualify for Medicare, federal health insurance for the elderly.
Matthews fits that profile. Growing up, she had insurance through her parents, and later through her husband, who worked in a family steel business. "I always had health insurance," she says.
After her husband died from leukemia in 1995, she worked as a marketing consultant, receptionist and administrative assistant. She last worked in 2006 as a front desk agent at a corporate conference center in Bryn Mawr. But she hasn't had health insurance since 2002. Without an employer to help with the premiums, she says coverage is beyond her reach.
She went back to school in 2007 to become a certified legal assistant, just in time for the recession to hit. Today, she trolls for jobs on her laptop, and tries to stay as healthy as possible, although she has not seen a doctor in years. There's a bowl of apples on her dining room table, and a treadmill in the living room of the brick Colonial she bought with her husband in the 1980s.
Matthews says she was surprised to learn that being unemployed with "no money in your checking account" counts for little in getting public health care. "It is pretty crazy," she says of the current system.
Young Also Struggle
About half of uninsured childless adults are between the ages of 19 and 34, and would be discouraged from working if they got free health care, critics say. "Medicaid should be focusing on people that Medicaid is uniquely qualified to serve, which are people with complex medical needs, people with disabilities," says Dennis Smith, head of Medicaid under President George W. Bush.
But Heather Jenkins, 29, a personal trainer living near Baltimore, says she can't get private insurance because of injuries she suffered in an auto accident a few years ago, leaving her with chronic jaw pain and hip problems. At the same time, her injuries are not considered extensive enough to get her free health care under federal disability laws.
The Medicaid expansion could help her: she now earns less than $15,000, and might meet the income criteria in an overhaul bill.
"I am hoping to still work and pay taxes. I cannot get Social Security (disability insurance) because I am not that disabled. But I am too disabled to get health insurance," she says.
Some candidates for the new Medicaid might not be considered so sympathetic. The overhaul would reverse a practice adopted as part of welfare reform in 1996 that made it more difficult for people with drug or alcohol addictions to get Medicaid coverage.
For years, Montez Tucker, 50, wrestled with alcohol and drug problems. The Philadelphia resident says he got clean three years ago after checking into a Christian mission treatment center. But he has no health insurance.
Today, he works about 20 hours a week, earning $10 an hour, as a package handler for an express mail company, low enough to qualify him for Medicaid under the proposed new rules.
"I really want to make more than $15,000 a year," says Tucker, a former National Guard paramedic, who is returning to school to become a certified nursing aide. "But (Medicaid) helps if you can't" make more.
He thinks expanding coverage for substance abusers would be money well spent.
"People want help and have no way to get it," he says.
This story was produced through collaboration between NPR and Kaiser Health News (KHN), an editorially independent program of the Henry J. Kaiser Family Foundation, a nonpartisan health-care policy research organization. The Kaiser Family Foundation is not affiliated with Kaiser Permanente. Copyright 2010 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.