According to a recent Commonwealth Fund report, in the states not expanding or still undecided about expanding Medicaid under the Affordable Care Act, 42 percent of people who did have not health insurance for some time in the last two years will not have access to health coverage in 2014. This means many of poorest residents of these states will fall through the cracks because of state inaction – the so-called “Medicaid coverage gap”. There is still a chance a few states will pass legislation (Pennsylvania) or act administratively (Ohio) to expand Medicaid. But for most states that have yet to act, Medicaid expansion is a dead issue until next year.

The Fund’s report suggests that Congress could step in and provide a solution by passing legislation to amend the ACA to make all adults with incomes below 100 percent of poverty eligible for subsidized private plans. Unfortunately, given the political dynamics in Washington, the chance of Congress acting on this is zero.

In the meantime, the Obama Administration could help those who fall into the Medicaid coverage gap by making sure that they know about the obligation of non-profit hospitals to provide charity care – or financial assistance. The ACA requires these hospitals to have written financial assistance policies that clearly specify eligibility criteria and to widely publicize these policies.   Through these policies people not able to access Medicaid would likely qualify for free or reduced cost care that could pay for some needed services. Unfortunately, too often these policies fly under the radar screen. Patients who qualify for help may not know enough to ask about the programs. Hospital admissions and billing staff can play a valuable role in proactively screening patients for charity care eligibility, but may not follow through in sending information about who is eligible and how to apply. In fact, patients and advocates in some states have reported that hospital staff ask patients to pay upfront for care, using credit cards or borrowing funds from family members, rather than screening them for financial assistance. To avoid these problems, uninsured people don’t seek needed care or end up with outrageous bills for services for which they should not be charged.

For uninsured patients in particular, financial assistance is an important safety net. Consumers, Navigators, and assisters should be able to easily find and understand what local hospitals offer and how people can apply. Hospitals have to file information about their policies annually with the IRS, but that information won’t be intuitive or easily accessible to most uninsured patients. A better solution would be to make information about hospital policies (e.g. who is eligible? what services are covered? how can patients apply?) available in a single website.

Hospitals are already required to make financial assistance policies widely available to the public, but the public may not know the policies are there. It is time to connect hospital financial assistance to the rest of the ACA. It could make a difference for millions of people.