Audrey Saylor is 52, works two jobs and has an auto-immune disorder that keeps her running between Anchorage doctors.
In the new health-care landscape under the Affordable Care Act, she's too poor to afford private insurance, but as a single woman with adult children, she also doesn't qualify for government-paid care under Medicaid.
Saylor is in the no-man's land of medical coverage, a place that wasn't supposed to exist when Congress passed the health care law in 2010. In the original law, Congress ordered the states to make coverage available to people like Saylor by expanding their Medicaid programs. But the U.S. Supreme Court struck down mandatory Medicaid expansion, leaving the decision up to the states.
In November, Gov. Sean Parnell announced that Alaska would not expand the program, leaving about 40,000 low-income people, like Saylor, who don't benefit from the health insurance marketplace or Medicaid. Expansion would have qualified every Alaskan with an income up to 138 percent of the poverty level -- about $19,800 for a single adult -- for Medicaid. Now they're just members of the "coverage gap." And to add insult to injury, they could be fined for not getting any insurance unless they apply for, and receive, a hardship exemption.
So Saylor, diagnosed with Graves' disease, an overactive thyroid condition, said she'll fill out an exemption application and continue to have her blood drawn monthly and take her medication daily as an uninsured Alaskan.
"It's very embarrassing when you've worked your whole life and you've been working two or three jobs and you have to beg someone to see a doctor," she said.
Saylor has two options to avoid the fine -- mail a hardcopy of the hardship exemption application from healthcare.gov anytime between now and next year's tax season or wait until she files her federal income tax return by April 2015 to prove that she landed in the Medicaid coverage gap.
Over at the Anchorage Neighborhood Health Center in Midtown, where counselors help people navigate the marketplace, a growing list of more than 60 people wait for information on hardship exemptions.
Currently, Alaskans must receive a Medicaid rejection letter from the state to include with the hardship exemption or tax return. But health officials said they are hoping the state and federal governments will streamline that process.
Samantha Longacre, a certified application counselor at the Neighborhood Health Center, said she doesn't want to inundate the state with Medicaid applications that everyone knows won't be approved, so she is waiting for word of a fix.
Meanwhile, she continues with a heavy appointment load of individuals and families who need assistance with the health insurance marketplace, set to close March 31 for this year's open enrollment. She said some people she helps still know very little about the health-care law.
"Some people get in and think that everybody is going to have health insurance or, 'Oh, I thought this was for poor people and I'm poor,' and you have to sadly explain to them that that portion, Medicaid, wasn't expanded," Longacre said.
Alaskans currently covered by Medicaid include parents and other caretakers, children, pregnant women and individuals in foster care up to age 26, said Ron Kreher, director of public assistance for the state health department.
Eligible incomes depend on the size and composition of the household.
"Folks who aren't covered, by and large, are single adults between 18 and 65 and couples," Kreher said.
They're the ones in the coverage gap who could face fines.
Saylor, a bartender at the Anchorage Convention Center and The American Legion, works six days a week and earns less than $14,000 a year. A member of Unite Here Local 878, Saylor responded in December to a Facebook message posted by the Democratic Party asking for people to share their stories about Medicaid or the Affordable Care Act.
If she made just a few hundred dollars more, and her income fell between $14,350 and $57,400, she could receive a subsidy (or tax credit) in the health insurance marketplace that would drive down her insurance cost. But since she doesn't, Saylor would have to pay the full price for health insurance, nearly $700 a month for a middle-of-the-road plan, she said.
"So I pay half my income, or pay the little fine or file for an exemption so I don't have to pay the fine and still have no insurance," Saylor said.
Saylor lives in a south Anchorage condo where she splits the rent with her 20-year-old son.
The fine, or what the health care law calls "individual shared responsibility payments," start at 1 percent of annual income or $95 a person, whichever is higher, in 2014 (taken out of your 2015 tax returns). The fine for an uninsured child is $47.50.
The penalty increases each year and by 2016, people without health insurance will be fined either 2.5 percent of income or $695 a person.
If a person has insurance through a job, his or her W-2 form will indicate coverage, said Steve Mahoney, a tax attorney with Manley & Brautigam. If a person is granted an exemption, he or she will receive an exemption certification number to write on the tax return.
Mahoney noted concerns about people and tax preparers getting tangled in the wide range of exemptions come tax season in 2015.
"Those first couple of years are going to be really bad," he said.
Susan Johnson, northwest regional director of the U.S. Department of Health and Human Services, has another concern. She said she's worried people will stop enrolling in the health insurance marketplace to file hardship exemptions, which aren't due for more than a year.
"So there's no hurry up," Johnson said. "You could do it now, you could do it when you file your taxes, you could do it anytime between then."
The pause could be problematic for families where children may qualify for Medicaid and parents do not, Johnson said.
Children qualify for Medicaid at higher household incomes than adults do.
Saylor said she doesn't plan to download the exemption application until after she completes her 2013 tax returns.
Saylor said she attempted to apply for health insurance in early October, during the glitch-plagued launch of the federal healthcare.gov website. That was when she realized that she fell in the coverage gap. "It really sucks to be poor and not have insurance," she said.
Reach Tegan Hanlon at email@example.com or 257-4589.
It's not just the Medicaid ineligible who may qualify for an exemption:
Other groups include:
- Members of federally-recognized tribes
- People whose income is too low to file a tax return
- Members of recognized health-care sharing ministry
- Members of recognized religious sects with religious objections to insurance
- Evicted in the past six months
- Received a shut-down notice from a utility company
- Recently experienced domestic violence
- Recently experienced the death of a close family member
- Experienced a flood, fire or other natural-caused or human-caused disaster that substantially damaged your property
More information at healthcare.gov/exemptions.