Kansas resident Suzan Emmons, center, earns $14,000 a year and cares for two young girls, Elizabeth and Jaiden, but does not earn enough to qualify for health-care subsidies. (Photo by Ana Swanson/The Washington Post)

Obamacare was designed to make it easier for poor Americans to buy insurance. In many states, though, the law has left a hole where less needy households can receive benefits, while millions of Americans living in poverty cannot. They are, in effect, too poor to get help.

It is one of several utterly maddening paradoxes in President Barack Obama's health-care overhaul, more formally known as the Affordable Care Act — which, due to GOP opposition, political gridlock and the Supreme Court, has never been fully enacted in the way Democrats intended.

Last week, The Washington Post profiled a Kansas woman named Suzan Emmons and the two young girls she cares for, her granddaughter and her granddaughter's half sister. Emmons is one of those who does not earn enough to qualify for subsidies. Several readers wrote in to say there must have been some kind of mistake. People are denied public benefits for making too much money, not too little, they wrote.

Emmons notes the oddness of her situation. “That's the weirdest thing, that I don't make enough money to qualify,” she said.

How we got here

Many Americans are in similar circumstances because the Supreme Court and Republican lawmakers and governors prevented a major component of Obamacare from being completely implemented. Now, according to the nonpartisan Kaiser Family Foundation (KFF), there are about 2.6 million Americans who would be eligible for financial assistance through the law if they made more money.

When Obamacare was enacted, Democrats imposed a minimum income requirement for those who wanted financial help buying private insurance under the law. As passed, the law would have instead covered those below the minimum through an expansion of Medicaid, the federal health-insurance program that covers many of the poor, elderly and disabled.

In 2012, however, the Supreme Court struck down that provision of the law, ruling instead that states had the option of expanding Medicaid, maintaining the current system for those with incomes below that minimum level of income.

In some states, Republicans did not expand coverage through Medicaid up to that minimum. As a result, many Americans who were excluded from Medicaid because they were not poor enough — or for other reasons — were nonetheless too poor to get any help through Obamacare.

These Americans are in what experts often call the Medicaid coverage gap. Many less needy households, meanwhile, are receiving subsidies.

“The Medicaid coverage gap is completely confounding to people, because it’s so counterintuitive,” said Sheldon Weisgrau, the director of the Health Reform Resource Project in Topeka, Kan. “It generally is jaw dropping to them.” His organization was established to represent the interests of patients in Kansas during health-care reform.

“You have to be above a certain income level to get financial help, rather than below, which is the way these things usually work,” Weisgrau said.

Health insurance in Kansas

In Kansas, parents must make no more than 38 percent of the official federal poverty level to qualify for Medicaid. That's only $7,800 a year, or about $150 a week, for a family of three.

Emmons cannot afford coverage on her own, and because Kansas Gov. Sam Brownback, a Republican, vetoed a bipartisan effort by state lawmakers to expand Medicaid in March, she is going without insurance.

Emmons makes $14,000 a year cleaning houses. If she lived by herself, she would be considered well off enough to receive a subsidy to buy private insurance through Obamacare.

However, since she took in the two girls, removing them from what she described as a dangerous home in Wyoming, the size of her household has increased to three, and she is worse off in the eyes of the law. On an annual income of $14,000, they are officially poor.

The two children are covered. Public programs for health insurance are generally much more generous for children than for adults. To qualify for subsidies for herself, though, Emmons would have to make at least $20,000 a year — the federal poverty level for a three-person household.

Instead, she is one of roughly 56,000 Kansans in the gap, according to KFF's estimate.

Around the country

Because each state's rules regarding who can receive Medicaid differ, the number of people in Emmons's situation varies across the country. In neighboring Missouri, for instance, parents who make more than just 18 percent of the federal poverty level are ineligible for Medicaid. That's just $70 a week for a family of three.

Both Kansas and Missouri, however, are particularly restrictive. The average maximum among all states that did not expand Medicaid is 44 percent of the poverty level, KFF found.

These figures are for parents. Although there are a few exceptions for pregnant women and those with disabilities, it is common for adults in these states who do not have dependent children to be ineligible no matter how much or how little they make.

Rachel Garfield, a researcher at the foundation, pointed out that nine out of 10 people in the gap live in the South. Southern states tend to have strict rules for Medicaid, and since Republicans dominate the region politically, few of them expanded the program under Obamacare.

“There is really a regional issue at play here,” Garfield said. “Most states not expanding coverage being located in the south, that is where most people who are in this situation live.”


More than half — 54 percent — of adults in the coverage gap are working, Garfield said. Many work for employers that do not sponsor health insurance, and because the rules on income are so strict, they are also barred from receiving subsidies or coverage through Medicaid.

The result is a “perverse” system, Weisgrau argued.

“If somebody got an offer of a better job at a higher salary, it puts them in the position of having to decide whether to turn the job down and keep their Medicaid coverage,” he said.

Ana Swanson contributed reporting from Iola, Kan.