The Cruelty of Republican States in One Chart

Many people are talking today about this article in today's New York Times, which focuses on the particularly cruel doughnut hole created when the Supreme Court allowed states to opt out of the expansion of Medicaid in the Affordable Care Act. The problem is that if you live in a (mostly Southern) state run by Republicans, you have to be desperately poor to qualify for Medicaid under existing rules. But it isn't until you get to 133 percent of the poverty level ($31,321 in yearly income for a family of four) that you're eligible for subsidies to buy insurance on the exchanges, because when the law was written the idea was that everyone under that income would get Medicaid. When all those Southern states decided to refuse the Medicaid expansion in order to shake their fist at Barack Obama, they screwed over their own poor citizens. So millions of people will be caught in the middle: not poor enough to get Medicaid, but too poor to get subsidies on the exchanges. But when we say "not poor enough," what we're talking about is people who are, in fact, extremely poor. And you'll be shocked to learn that in those states, the poor are disproportionately black. Could that have anything to do with it? Heavens, no!

In any case, I thought it might be worthwhile to lay out in one handy chart how, state by state, this will affect people. Under pre-ACA law, each state sets its own eligibility level for Medicaid. In more liberal states, these levels are fairly high; for instance, Massachusetts gives Medicaid to families up to 133 percent of poverty, New York up to 150 percent, and Minnesota up to 215 percent. But in conservative states, the levels are far stingier; as someone in the Times article says, "You got to be almost dead before you can get Medicaid in Mississippi." In addition, in most states childless adults can't get Medicaid no matter how poor they are, but under the ACA it will no longer matter whether you have children. This is just one more way conservative states that forego the Medicaid expansion (for which the federal government is picking up almost the entire tab, by the way) are harming their own citizens.

On to our chart. One note: most states have different levels for working and non-working people; the levels are higher for those with jobs. I've used the figures for working families. The bars in red are the states that have rejected the Medicaid expansion, and as you can see, almost all of them are clustered at the lowest end of the eligibility spectrum. That means that the states where the Medicaid expansion would have done the most good for the most people are precisely those states where Republican governors and legislatures have told their poor citizens that they're out of luck.

When you look at these income eligibility levels, you see just how cruel the existing system is. For instance, in Alabama, you can't get Medicaid if your income exceeds 23 percent of the poverty level, or $4,500 for a family of three. Just think about that for a second. Do you think you could find a place to live, pay your bills, and feed your family on that income? But the state of Alabama says if you're that rich, you can afford to buy health insurance. In Texas, the state that will be depriving the most people of insurance by rejecting the expansion, only families under 25 percent of the poverty level, or $4,894 for a family of three, will be eligible for Medicaid. I'm guessing that's about what Rick Perry spends on boots every year.

It may be that in the next few years, many of those states will give in and accept the money, instead of making their poorest citizens the victims of their loathing for Barack Obama. Let's hope.


Some 50.4% of all children in the U.S. either receive Medicaid (41%) or are uninsured (9.4%) according to the Center for Budget and Policy Priorities report "Policy Basics: Introduction to Medicaid". We are too poor for most parents to afford medical insurance for their children.
About 36% of U.S. citizens (including children) are either uninsured (16%, or 50 million) or receive Medicaid (20% or 67 million). We are too poor as a nation for that minority to afford medical care.
"In the typical state, Medicaid eligibility is now limited to working parents with incomes at 61 percent of the poverty line [$11,913 for a family of three] and unemployed parents at 37 percent [$7,226 for a family of three] of the poverty line." says the report.
Childless adults (except if they are disabled) are not eligible for Medicaid no matter how poor they are. But children under six require "mandatory" Medicaid for incomes up to 133% of the poverty level, $25,975 in a three person family. After the child is between 7 and 18 the income level for mandatory coverage drops to 100% of poverty level. If one is poor, the first priority is to have a child, then find a job no matter how low the pay.
"In the poorest states, the federal government pays 73 percent of all Medicaid service costs; the national average is about 57 percent," the report states. It spent $414 billion in 2011.
Medicaid spends its money this way: 44% for blind and disabled, 20% for seniors, 21% for children, 15% for adults. $19,530 is the poverty level for a family of three in 48 states according to the HHS guidelines for 2013.

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My economics blog is at, and I've just posted a letter-to-the-editor about Obamacare and Inequality on the blog. The CBPP report also stated that 93% of the expansion costs would be borne by the federal government until 2022. "And by greatly reducing the number of uninsured, the expansion will enable states and localities to save substantial sums on uncompensated care for the uninsured. " Not only will this increase the employment of the medical industry, it will save the states on "uncompensated costs". What a no-brainer!

Nothing will change until the voters in the Red states wake up to what the politicians they keep voting into office are doing to them. At least here in Pennsylvania we stand a good chance of getting rid of One-Term Tom Corporate as governor. But until we turn at least one house of the General Assembly Blue little will change here.

The Tea Party do not believe ANYBODY who is poor, REGARDLESS of how disabled, old, young, or otherwise disadvantaged he or she may be, deserves A PENNY of assistance unless another person decides to give help voluntarily as charity. NO EXCEPTIONS, which would bring back the street begging (which brings housing in the form of jail), Little Match Girl, workhouses, Dickensian environment which killed so many (including death by hanging for children stealing bread to eat). The same people who claim to believe that every life is precious to God are overeager for God to get them back as soon as possible if they cannot make themselves precious to the economy. The very same groups who deny that Darwin's principle of "survival of the fittest" (as MIS-understood by so many) describes the nonhuman natural world believe that it SHOULD apply in the human world.

To be fair, SOME of the Tealiban are HONEST about not believing in God, as their idol Ayn Rand did not, but too many are hypocrites who clothe their hate and heartlessness in phony Christian theology. Reference, among other scriptures, Matthew 25.

Medicaid payments will likely bankrupt the rural NY county I live in, so I don't see self-preservation as cruelty.

Likelihood is not certainty. And while trying to hash out how to perfectly solve the problem, the main function of the state (as a proxy for society) should be to ensure that its citizens live in dignity. Without that, what use do we have for an army to protect it (that swallows vastly more than any Medicaid, Social Security, etc do).

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The two most liberal red outliers, Maine and Wisconsin, are not classically "red." Wisconsin was pretty blue for a long time and that limit is a legacy of those days. Maine was once famously Republican but had gone Dem for several decades before recently going red again. Both states may well return to the red side.

Make that "both states may well return to the BLUE side."

AMEN! The only thing Texas can claim they're doing to help people is provide measly little jobs! California is the blue print we should follow. We're doing so well we're building bullet trains and stopping climate change. Let's hope the country follows California's stellar leadership and eradicates low wage jobs and promotes eco-diverse play ground equipment.

Look at the "Basic Family Budget Calculator" at, and in Houston the family of two parents and one child need for basic expenses and income of over $56,000 per year, of which medical insurance sucks up 28%, and child care about 12%. In the nation, in 2 out of 3 states if the family of three earns less than poverty, which in 2014 is $19,790, they are excluded from Medicaid, and level of exclusion varies. If Mom, Dad, and child earns more than $4,000 in Arkansas you are out, they are the worst. I do not understand why the Democratic Party does not work on this issue, especially in the states with high poverty and exclusionary Medicaid levels and rejection of Obamacare. I would think this would turn elections. The average household income in the U.S. is over $100,000 (including pension, Social Security, health insurance) and "cash income" average is over $75,000, and savings is about $690,000 according to Fed. Reserve Flow of Funds report. It is incorrect to believe the nation cannot afford basic medical services to everyone.

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