Haves and Have-Nots as Health Care Markets Open

WASHINGTON (AP) -

Having health insurance used to hinge on where you worked and what your medical history said. Soon that won’t matter, with open-access markets for subsidized coverage coming Oct. 1 under President Barack Obama’s overhaul.

But there’s a new wild card, something that didn’t seem so critical when Congress passed the Affordable Care Act back in 2010: where you live.

Entrenched political divisions over “Obamacare” have driven most Republican-led states to turn their backs on the biggest expansion of the social safety net in a half century. If you’re uninsured in a state that’s opposed, you may not get much help picking the right private health plan for your budget and your family’s needs.

The differences will be more glaring if you’re poor and your state rejected the law’s Medicaid expansion. Unless leaders reverse course, odds are you’ll remain uninsured. That’s because people below the poverty line do not qualify for subsidies to buy coverage in the markets.

“We are going to have a new environment where consumers may be victims of geography,” said Sam Karp of the California HealthCare Foundation, a nonprofit helping states tackle practical problems of implementation. “If I’m a low-wage earner in California, I may qualify for Medicaid. With the exact same income in Texas, I may not qualify.”

The health care law is finally leaving the drawing boards to become a real program with citizens participating. But in many parts of the country the decisions of Republicans opposed to the law will trump the plans of Democrats who wrote it.

Still, there is a new bottom line. Health insurance marketplaces in every state will provide options for millions of people who don’t have job-based coverage, who can’t afford their own plan or have a health problem that would get them turned down. The feds will run the markets in states that refused to do so.