The frosty weeks before the holidays were always the hot season for Andre Butler. He would head downtown, looking snappy in his "blacks and whites" - industry argot for tuxedos - to work as a bartender, server, or host in Center City's finest hotels.
But post-recession, those parties have become fewer and smaller. The only reminder for Butler of those days is the constant ache in his legs and hips from the years of lugging heavy trays. He needs tests to pinpoint the cause of his pain, but lacks insurance or the money to pay out-of-pocket.
"Right now, I have basically relegated myself to heating pads, Tylenol, and Motrin," Butler, 48, of Chestnut Hill, said.
Butler, who has never had a job with insurance, was hoping to buy a plan on the Affordable Care Act marketplace. But he earns too little to qualify for the exchange.
Even more frustrating, he makes too much for Medicaid.
And because Pennsylvania has so far declined the federal money to expand Medicaid, Butler will likely enter the new year uninsured.
"When a politician goes to a hotel to have a function, it is the housekeeper, bell captains, the front desk people, the concierge, and the parking valets who they count on to help them," Butler said. "Like myself, they don't have health insurance. We need our health insurance."
As many as 400,000 Pennsylvanians will plunge into the hole between traditional Medicaid and the new marketplace come Jan. 1, according to the Pennsylvania Health Access Network.
"The overwhelming majority of these people are working," said Athena Smith Ford, the network's advocacy director. "Seventy-five percent of them have at least one full-time worker in the household. We're talking about hairdressers, home health aides, auto mechanics, and servers, people who work in low-wage jobs that don't come with health insurance and who don't make enough to purchase it in the private insurance market."
That gap was supposed to be filled with federal money states could use to cover more people. Gov. Corbett first chose to turn down the so-called Medicaid expansion. Officials have since presented a 12-page plan called Healthy Pennsylvania to the federal government. The aim is to reform Medicaid, increase access, and stabilize financing. The feds have yet to render a decision on the plan.
"We continue to meet and talk with the U.S. Department of Health & Human Services about the Governor's Healthy Pennsylvania plan and specifically, the plan for Medicaid reform," e-mailed Christine Cronkright, the governor's deputy communications director. "These discussions are helping to inform our process in drafting a waiver for the Medicaid program that will require approval by the federal government. We are working through that process as quickly as possible and are hopeful on the front end that conversations with the Centers for Medicare & Medicaid Services and our recent submittal of the formal white paper outlining our requests will expedite approval of the waiver."
Though Ford and other members of the Cover the Commonwealth Campaign view Healthy Pennsylvania as a good first step, they said the Medicaid expansion would save taxpayers up to $1 billion over the next decade.
"There is bipartisan support in the state House and Senate," she said. And a recent American Cancer Society poll found that most Pennsylvanians agreed accepting the federal money "is the right thing to do."
Not taking the money to expand Medicaid may also affect the fiscal health of hospitals. Under the old insurance system, hospitals received federal money to help offset the cost of treating uninsured patients. But the health law eliminates a large chunk of that money beginning in 2015.
"Our hospitals are going to lose at least $8.1 billion in the next 10 years in funding to help pay for uncompensated care," Ford said. "The hospitals were willing to give it up because they said it was actually going to benefit them if the majority of Pennsylvanians have health insurance coverage either through Medicaid, the marketplace, or an employer."