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NEW YORK (MainStreet) – The decisions of 22 states not to adopt the Medicaid expansion with three states still undecided will leave large numbers of some of the nation's poorest people without health insurance.

Leaving this gap group uninsured was an unintended consequence of the U.S. Supreme Court ruling last year that states were not required to expand Medicaid to continue receiving federal funds for existing programs when it handed down its decision that it was constitutional to require most uninsured Americans to buy health insurance.

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The Medicaid expansion that was included in the Affordable Care Act attempted to fill a longstanding gap in Medicaid coverage for adults by expanding eligibility to those low-income Americans who make less than 138% of the federal poverty level.

Rather, as many as 6.4 million uninsured people will have no healthcare coverage, according to a Kaiser Family Foundation report. Further, this gap group will not qualify for tax subsidies that would have helped them afford health insurance in the new marketplace.

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The Centers for Medicare & Medicaid says that they will not be responsible for paying the penalty for not having insurance coverage. Qualifying individuals and families in the gap who live in the states expanding Medicaid will get healthcare coverage through Medicaid and "is potentially a terrific benefit to millions of people in the country," says Louis Feuerstein, partner at ParenteBeard, a tax, accounting and business advisory firm.

However, Feuerstein adds that limited access to quality doctors coupled with the low payment rate to hospitals, which he says may make the Medicaid patient "a lower service priority," "may limit the options to support the healthcare needs of Medicaid patients, and ultimately, those individuals may be back in the same situation as when health coverage was determined by income and other demographic factors."

Catherine Sreckovich of Navigant Consultings warned of the consequences. "Physicians will likely continue to favor Medicare patients over Medicaid patients because reimbursements are higher, though they will likely favor those with commercial insurance over both Medicare and Medicaid," she said.

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The Medicaid expansion will go into effect on January 1, 2014, along with the healthcare marketplaces.

--Written for MainStreet by S.Z. Berg, author of College on the Cheap.