10/22/2014 10:28 am ET Updated Dec 22, 2014

Medicaid Expansion Politics Have Endless Repercussions

The Affordable Care Act (ACA) -- "Obamacare" -- has turned out to be a great way to measure political character.

For people living near or below the poverty level -- those making roughly $15,500 a year or less -- the ACA was supposed to offer insurance through an expanded Medicaid program. Before the ACA, only children in poverty and certain adults were eligible for Medicaid. The new law meant that most people living below the poverty level could be eligible for Medicaid. And the federal government would cover the entire tab for new enrollees for three years, and thereafter pay 90 percent of expenses.

Yet in 23 states, the legislature is protesting the ACA by rejecting the expansion, thus building their political grandstands on the backs of the poor.

Without Medicaid, millions of Americans must delay getting care because they are afraid of incurring costs they cannot afford. In states that rejected expansion, low-income people often rely on hospitals for emergency and other needed care. Thankfully, in most states, non-profit hospitals must provide certain financial assistance to indigent patients. The problem is that those patients rarely know about the financial assistance policies before they go to the hospital and hospitals may charge more for care for uninsured patients than for those with insurance.

The ACA, for the first time, requires tax-exempt hospitals to have reasonable billing and collections practices to help reduce the threat of medical debt that prevents many people living in poverty from seeking care. While the details are left to individual facilities, at a minimum, a tax-exempt hospital must limit the amount it bills low-income people for emergency or medically necessary care to what it generally bills patients who do have insurance. In short: hospitals cannot take advantage of a patient's uninsured state. These hospitals also must publicize their policies so low-income patients know that they may have a defense against a high bill.

When that doesn't happen, patients can find themselves in a situation like Jacqueline Samuels, a low-income patient battling end-stage renal disease. Under the charity care program at her tax-exempt provider, Jackson Health Services ("Jackson Health") in Miami-Dade County, her outpatient procedure should have cost no more than $200. She was billed $4,524.

How did this happen? Unlike the other non-profit hospitals in the area, Jackson Health largely fails to publicize its charity care program. You have to really dig through their website to find it. Jackson Health also does not tell recent patients receiving bills that they might be eligible for financial help.

These aren't just impolite things to do.

Federal law is meant to prevent this type of bad behavior. Hospitals are only entitled to tax-exempt status if they actually make efforts to publicize their financial assistance policies and notify patients that they might qualify. Otherwise, hospitals get to have their cake and eat it too: they get the benefit of being classified as a charity without having to fulfill their charitable mission.

In response to stories from Ms. Samuels and patients like her, Florida Legal Services and my organization, the National Health Law Program, recently took legal action against Jackson Health.

Our action was a first for advocacy organizations. We did not file a lawsuit in a court. Instead, we asked the IRS to enforce its regulations. After all, the ACA's protections are only as strong as the enforcement of those protections. Our complaint challenges Jackson Health's classification as a tax-exempt organization, a benefit it receives at taxpayer expense, despite failing to live up to its charitable promise.

Mrs. Samuels' predicament has since been sorted out, although with legal assistance and only after collections agencies started circling. If our complaint yields results, others will be spared her experience. The IRS may not be the agency you expect to vindicate patient rights, but it may have the best leverage to do so.

The bigger picture that we cannot lose sight of, however, is that Samuels and other struggling hard-working Americans would not be in this situation if Florida had expanded its Medicaid program. Samuels joins 165,000 other Miami-Dade County residents caught in a vicious "coverage gap"--they are locked out of both Medicaid and subsidized insurance on the Marketplace. As a result, they rely on charity care providers for basic health care, and often go without care.

So while Jackson Health's policies are unacceptable, the hospital also feels the brunt of Florida's political games, along with the thousands of others languishing without medical care. The only thing standing in the way is Florida's legislature. Its high time Florida (and 22 other states) got on board and expanded Medicaid.