HARRISBURG -- About 5 million people will be without health care next year that they would have gotten simply if they lived somewhere else in America.
They make up a coverage gap in President Barack Obama's signature health care law created by the domino effects of last year's Supreme Court ruling and states' subsequent policy decisions.
The court effectively left it up to states to decide whether to open Medicaid, the federal-state program for the poor and disabled, to more people -- primarily poor working adults without children. Twenty-five states declined.
That leaves 4.8 million people in those states without the health care coverage their peers elsewhere are getting through the Medicaid expansion, according to a Kaiser Family Foundation estimate. More than one-fifth of them live in Texas alone, Kaiser's analysis found.
Among those in the gap is Cheryl Jones, 61, an Erie part-time home care worker, who makes do without health insurance by splitting in half high blood pressure pills she gets from a friend, not a pharmacist. She would also like to visit a dentist to fix her broken partial dentures. A new pair of glasses might be nice, too.
"There are a lot of us who need medical help now," she said. "I need new glasses, I need to go to a dentist, I need my medicine. ... Think about us working poor. We pay our taxes."
The Medicaid expansion was supposed to work hand-in-hand with tax credits subsidizing private insurance for those with slightly higher incomes, two keys to the law's broader aim of extending health insurance to 30 million more people. As an enticement for states to expand Medicaid, the federal government promises to pay nearly all of the cost.
Without expansion, the law is unable to help those below the income threshold where tax credits kick in, about $11,500 for working adults.
On Wednesday, 24 states and Washington, D.C., will extend Medicaid to more than 4 million adults who would otherwise fall into the same gap as Ms. Jones. Access to the care they'll get is similar to that of those with private insurance, said Joan Alker, executive director of Georgetown University's Center for Children and Families.
A 25th state, Michigan, plans to expand in April. Wisconsin effectively eliminated its gap without using the more generous federal contribution.
Politics is apparent in states' expansion decisions. Of those that did, all but five supported Mr. Obama in last year's election. Of those that declined, most are more conservative states in the South, Midwest and northern Rockies that voted against Mr. Obama.
One outlier is Pennsylvania, a moderate industrial belt state that supported Mr. Obama twice.
Republican Gov. Tom Corbett, who as attorney general sued unsuccessfully to overturn the health care law, instead plans to ask the federal government to approve an alternative to Medicaid expansion. He wants to use the law's generous Medicaid dollars to cover the same population via private insurance firms, while stripping down existing benefits under Medicaid, a target of conservatives' criticism.
With no guarantee of federal approval, hundreds of thousands of Pennsylvanians -- Kaiser estimates 281,000 -- could be stuck in the gap until at least 2015.
Mr. Corbett doesn't apologize for not expanding eligibility now. Administration officials say they want to be in a better position to create a successful, affordable program. "Our goal is to absolutely get this plan approved, so that every uninsured Pennsylvanian has health care options," Corbett aide Todd Shamash said. Mr. Corbett's office declined an interview.
Meantime, the uninsured who fall into this new Medicaid gap are selective about seeking care. "Their health care needs don't go away just because they're uninsured," Georgetown's Ms. Alker said, "and what they're missing out on is consistent primary and preventive care."
Shelagh Collins of Forest Hills in suburban Pittsburgh can get primary care at a federally funded community health center nearby, but can't afford more specialized treatment for joint pain that limits her ability to do certain jobs, she said. After she fell and hurt her hip in the spring, she couldn't pay for an MRI, she said. A friend's loan of $200 covered a month of physical therapy, but it didn't make the pain disappear.
Ms. Collins, 56, used to be a high-level administrative assistant at the Chicago Botanic Garden. Now, she gets by on occasional secretarial temporary work and unemployment compensation checks and tries to protect a 401(k) retirement account of $21,000 that she said makes her ineligible for Pennsylvania's current Medicaid program.
But the job market is brutal, temp work scarce, and her unemployment compensation is at an end, she said, adding, "I have never gone through anything like this in my life."
Lori Miller, 34, of Punxsutawney would like to see a doctor for headaches, blackouts and weakness that has made it difficult for the seamstress to pursue more work. She wonders if she's still suffering from a bicycle accident two years ago, for which she never sought treatment.
Living on about $7,000 a year, she said she can't afford a doctor visit. "I want to feel like that's an option to me, without worrying about, 'Do I have enough dollars to do that?' "