Publisher Health

ALBANY, Ga. — After giving up on their goal of creating a new Medicaid program to cover two million poor adults, Democrats are aiming to provide them with free private coverage as part of the party’s social policy bill. But there is a catch: The benefits would last only four years.

Even with that expiration date, the legislation cannot come fast enough for people like Evelyn Davis, who suffered two heart attacks and has high blood pressure and diabetes. A former home health care aide, she lost coverage when she got divorced two years ago. She has chest pains and heart palpitations but said she cannot afford to see a cardiologist.

“If I can’t get any medicine, I just get Tylenol PM when I sleep,” Ms. Davis, 63, said, “and just pray to God when I wake up that I won’t be in pain.”

She is among an estimated 2.2 million American adults who lack insurance because they live in one of the 12 states where Republicans have refused to expand Medicaid, which is jointly financed by the federal government and states, under the Affordable Care Act. Too poor to qualify for subsidized private insurance through the Obamacare exchanges yet not poor enough for Medicaid, they navigate a byzantine system of charity care — and often skip care altogether.

Now these patients may get what many have hoped for since the Affordable Care Act’s passage more than a decade ago — albeit with no guarantee that the new benefits are here to stay. The framework announced last week by President Biden for the $1.85 trillion social policy bill includes the biggest expansion of health care since the Obama-era health law, patching holes in the landmark law that had long seemed impossible to fix.

Still, the framework is tenuous. On Monday, Senator Joe Manchin III, Democrat of West Virginia, dashed hopes for a quick Senate vote by refusing to endorse the measure, whose health care provisions had already been pared back under pressure from Mr. Manchin and other centrists to keep the price down.

The “public option,” promoted by Mr. Biden during his presidential campaign as a way for people to buy into a Medicare-like plan, was never even considered. Language authorizing the government to negotiate prices with drug companies was scrapped. A plan to give dental, vision and hearing coverage to Medicare recipients has been whittled down to just hearing.

And in the end, negotiators dropped the idea of a new Medicaid plan financed entirely by the federal government for people in the 12 holdout states, which would have been complicated to create, in favor of fully subsidized private coverage — but only through 2025.

The free plans would be comparable to Medicaid coverage, with minimal fees for doctor visits and enhanced benefits like transportation to medical appointments. All told, an estimated 4.4 million people — including the uninsured and other low-income adults — would be able to take advantage of them.

For Democrats, who took back the House in 2018 and this year gained control of the Senate in part by vowing to expand access to affordable heath care, the bill is a political necessity. And perhaps no Democrat needs it more than Senator Raphael Warnock, Georgia’s first Black senator, who won a special election in January on a promise of expanding Medicaid.

Mr. Warnock will be on the ballot again in 2022, a year that is widely expected to be grim for his party, and the contest could determine control of the Senate. In Washington, closing the coverage gap remains Mr. Warnock’s signature issue.

“I believe that health care is a human right, and if you believe it’s a human right, you don’t believe it’s a human right for 38 states,” Mr. Warnock said in an interview in September.

But some Democrats, notably Mr. Manchin, view solving the problem solely with federal dollars as unfair to states that did expand Medicaid and continue to pay 10 percent of the cost; why, they ask, should Republicans be rewarded for resisting? Republicans oppose the social policy plan in its entirety, calling it a “tax and spending spree.”

The profile of those who fall in the gap is much the same as the profile of those hardest hit by the coronavirus pandemic: poor people of color. Most are in the South; Texas alone accounts for more than a third of people in the gap, according to the Kaiser Family Foundation.

Della Young, 49, a kidney transplant patient with lupus, was doing fine when she lived in New York. As an end-stage renal disease patient, she is covered by Medicare, which paid 80 percent of her medical expenses. Medicaid picked up the rest.

But when Ms. Young moved to McDonough, Ga., in 2015, she lost her Medicaid coverage and was unable to pay for drugs to prevent her body from rejecting her donated organ. Her transplant failed in 2016, and she has been waiting for a new kidney ever since, while undergoing dialysis three times a week. She sends the dialysis center a check for $5 a month — a small offering toward a much larger bill.

Because out-of-pocket expenses associated with transplants are so high, Emory Transplant Center, where Ms. Young is a patient, advised her to raise money on her own. She started a GoFundMe account, hoping to raise $100,000. She has raised $5,077 so far.

“This whole fund-raising thing is crazy,” she said. “Health care should be the same across the board, regardless of what state you live in.”

In Albany, a small city about three hours south of Atlanta, patients like Ms. Davis are eager for any help they can get. She and about a dozen other uninsured people shared their stories in the bare-bones waiting room of the Samaritan Clinic, founded 15 years ago by the Rev. Daniel Simmons, the senior pastor of Mount Zion Baptist Church, who said he had followed the will of God.

“People were suffering, dying right in our backyard,” he said. “I said, ‘Lord, what do you want me to do?’”

Still, the clinic can only do so much. Lisa Jones, 59, lost her employer-sponsored insurance when she gave up her job at a chicken processing plant to care for her ailing husband. He put her on his plan, but when he died she fell into the coverage gap. She gets blood pressure and cholesterol drugs through the clinic, which works with companies that offer free medicines.

But when Ms. Jones sought care for Covid-19, she got a bill for $150. “That went to collections because I didn’t have the money to pay it,” she said.

Volunteer doctors provide primary care at the clinic, but Nedra Fortson, a nurse practitioner and the clinic’s executive director, said it was difficult to refer patients to specialists because so many refuse to offer free care.

Some patients, she said, can afford to go to the community health center, which has a low co-payment of $25. “But oftentimes, once they get in to see a provider and they have to run labs, the patient ends up having a bill,” Ms. Fortson said. “And once they can’t pay that bill, they are unable to get appointments, and so they come to us to get help.”

The question of Medicaid expansion has percolated through Georgia politics for much of the past decade. The Affordable Care Act intended for states to expand Medicaid to cover adults with incomes up to 138 percent of the federal poverty line — currently about $17,800 a year for an individual. Republican states sued, and in 2012 the Supreme Court upheld the law but made Medicaid expansion optional.

In 2014, Georgia Republicans went one step further. Fearful that a Democrat would win the governorship, they passed a law requiring the legislature to approve any expansion plan. In 2018, Stacey Abrams, the Democratic candidate for governor, hit Republicans hard on health care. The next year, the state sought to partially expand Medicaid, with requirements for recipients to work.

The Trump administration approved the plan, which would have covered only a fraction of the state’s uninsured low-income adults, just days before Mr. Trump lost the 2020 election. The Biden administration, opposed to work requirements, has put it on hold.

In the meantime, people in the coverage gap are trying to make do — now with new hope that the social policy bill will become law. Ms. Davis, the former home health care aide, pays $90 out of pocket to see a primary care doctor once a year and gets annual mammograms from the county health department, where they are free. Her children help, but she does not like to accept it.

The Democrats’ plan to fully subsidize four years of coverage would tide Ms. Davis over until she turns 65 in two years and becomes eligible for Medicare. She sought Social Security disability benefits, hoping to qualify for Medicare that way, but was unsuccessful.

“I filed for disability and they denied me,” she said, “and I’m like, ‘Oh Lord, it ain’t so much about the check.’ If I could just get some insurance so I could see my doctors, that’s all I want.” She added, “If I could get four years, it would be great.”