Reuters

More than 350,000 uninsured poor in the Dallas/Ft. Worth metro area alone are missing out on health coverage.

The Affordable Care Act promised a massive expansion of health care coverage for poor, uninsured adults. They would not have to sort through private plan options on the various exchange websites. They would not have to figure out federal subsidies, or find the money to pay for premiums that the subsidies would not cover.

Instead, people making less than 138 percent of the federal poverty line were supposed to qualify for a new and sweeping expansion of Medicaid, the public insurance program for the poor. Nearly half of the states, though, have so far opted not to adopt this part of the law (or take the federal money that comes with it). As I wrote in November, this decision has fallen particularly hard on large urban centers in states like Georgia, Texas, Florida, and Pennsylvania.

Why? Metropolitan areas are home to hundreds of thousands of poor people. Their public hospitals and health infrastructure function as magnets for the sick from surrounding counties. And in most cases, local taxpayers support that indigent care directly, meaning that any health-care money states reject from the federal government must be covered by urban residents instead.

When I wrote about this issue last fall, it was difficult to nail down concrete numbers for exactly how many uninsured adults were going to be left behind in Atlanta or Dallas or Orlando by governors and state legislators ideologically opposed to Obamacare. The Kaiser Family Foundation had produced a lot of good data at the state level. But no comparable statistics existed at the metro or county level. And several cities told me that they didn't have solid numbers themselves.

Now the Urban Institute's Health Policy Center has calculated these figures for the first time, using American Community Survey data from 2009, 2010, and 2011 to grasp, at the metro level, how many people will likely lose out on health coverage in states that have turned their backs on this part of the law. The totals are staggering. In the Dallas/Fort Worth metropolitan area, 357,000 adults living below the poverty line who would have qualified for Medicaid under the new law won't get it because of Texas' decision not to expand.

These adults likely will remain uninsured, because they're too poor to qualify for subsidized plans on the health exchanges, and not poor enough to qualify for Texas' stingy Medicaid program pre-dating Obamacare.

In the Miami/Ft. Lauderdale metro region, the number is 330,000 adults.

In metropolitan Atlanta, it's 327,000.

This is the list of the 25 most populous metro areas where adults who would have been eligible for Medicaid in another part of the country won't get it, based on the Urban Institute's analysis:

Adults between 100 percent of the poverty line and 138 percent are eligible to buy private insurance at subsidized rates. But if the state of Texas were expanding Medicaid to the full 138 percent threshold, in total more than half a million additional people in the Dallas/Fort Worth region alone would be covered under the public program. Instead, the region must hope that at least those adults just above the poverty line purchase subsidized private care instead.

These figures don't include poor children, who are already covered. Under existing programs, many states exclude single adults without children from qualifying for Medicaid. That means the Medicaid expansion was likely to help two groups in particular: poor parents who are not quite poor enough, and poor adults without children.

The resulting numbers are so large in Texas, Florida, and Georgia in part because current Medicaid laws there are among the least generous in the country. In Texas, for instance, an unemployed parent must make less than 12 percent of the federal poverty line to qualify for Medicaid. Poor adults in states that have rejected the Medicaid expansion, in other words, stood to benefit from it the most.

The Urban Institute has also mapped this data in several ways here. In this picture, you can see in dark purple where uninsured adults below the poverty line are clustered who would have been newly eligible for Medicaid:

Urban Institute

This is the state of Texas, with deep purple spots around Austin, Dallas, Fort Worth, Houston, El Paso, and San Antonio.

This map illustrates why Medicaid expansion will increasingly become a subject fought not between red states and blue ones, but between mayors and governors.

Top image: Lucy Nicholson/Reuters

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