Vol 23, 2014 Annals of Health Law 50
THE ACA AND PEOPLE LIVING WITH HIV/AIDS
Supreme Court held in National Federation that Congress did not have the
authority to completely rescind federal Medicaid funding for states that do
not expand eligibility standards, the Medicaid expansion provision of
PPACA became voluntary.177 This will create substantial medical care
access issues in states that choose not to expand eligibility standards.178
Aside from the obvious fact that the stricter eligibility requirements will
result in less people being covered under Medicaid in states that do not
expand,179 there is an additional problem with the newly optional
expansion. Childless adults whose income falls below the FPL will fall into
a gap in which they qualify for neither Medicaid nor federal subsidies to
purchase private insurance.180 PPACA also does not address longstanding
disputes over Medicaid reimbursement rates between medical service
providers and states, which has resulted in a debilitating shortage of
participating physicians.181 For PLWHA, who receive health care through
Medicaid and other government programs at disproportionate rates, these
access issues are especially important.182
1. The Medicaid Coverage Gap
The initial and most obvious effect of states opting out of the expansion
will be that less people will qualify for health coverage. A second,
unintended consequence is that childless adults with incomes below the
FPL will be denied both Medicaid and federal subsidies to purchase private
insurance.183 Beginning in 2014, PPACA authorizes federal subsidies to
purchase private insurance for those who earn between 100% and 400% of
the FPL.184 These subsidies will take the form of tax credits, which vary
based on the applicant’s income.185 If every state expanded Medicaid
eligibility as Congress intended, every American would fall within the
177. Nat’l Fed’n of Indep. Bus. v. Sebelius, 132 U.S. 2566, 2607 (2012).
178. See infra Part IV. B. 1.
179. Kaiser Family Found., Faces of the Medicaid Expansion: How Obtaining Medicaid
Coverage Impacts Low-Income Adults 1 (2013), http://kaiserfamilyfoundation.files.
180. See infra Part IV. B. 1.
181. See infra Part IV. B. 2.
182. See Crowley & Kates, supra note 4, at 2.
183. See Cal. Healthline, Millions Could Enter Coverage Gap Without Medicaid
Expansion (July 18, 2012), http://www.californiahealthline.org/articles/2012/7/18/millions-
184. Kaiser Family Found., Explaining Healthcare Reform: Questions About Insurance
Subsidies 1, 3 (July 2012), http://www.kff.org/healthreform/upload/7962-02.pdf.
185. Id. at 1.