About 25,000 poor and uninsured Mainers will miss out on health insurance under the Affordable Care Act because the state refused to expand Medicaid, according to a national study released Wednesday by the Kaiser Family Foundation.

Those individuals fall into the “coverage gap,” a health reform law no-man’s land encompassing nearly 5.2 million Americans who live in many Republican-led states, including Maine, that don’t plan to expand Medicaid to cover more low-income residents. Adults who fall into the gap earn too much to qualify for existing Medicaid programs but too little to qualify for federal financial help to buy private health insurance in the new marketplaces set up under the law.

The architects of the law intended for the Medicaid expansion to cover more low-income Americans, while federal subsidies available through the marketplaces would make coverage more affordable for those with higher incomes. But a June 2012 Supreme Court ruling made the expansion of Medicaid optional for states. Maine, along with 26 other states, opted out.

That left a big and unexpected loophole.

The ACA, or “Obamacare,” would have set a national eligibility level for Medicaid of 138 percent of the federal poverty level, or $15,856 for an individual and $26,951 for a family of three. Tax credits are available through the marketplaces to those earning from 100 percent to 400 percent of the poverty level — or $11,490-$45,960 for an individual, and $19,530-$78,120 for a family of three.

Health advocates are now attempting to explain to many low-income individuals that they’re, counterintuitively, too poor to get subsidies.

In Maine, 24,390 people fall into the coverage gap, and many are likely to remain without health insurance, according to the Kaiser analysis.

John, a 60-year-old man who lives in the Rangeley area, said he’s one of them.

“I feel left out, like I’ve been thrown under the bus,” he said.

John has an intestinal condition called ulcerative colitis that interferes with his ability to work, but he’s not on disability. He survives on his savings and income from a small rental property, he said. He has relied on the state’s Dirigo Health insurance program in the past, but Dirigo will phase out at the end of the year.

He can’t understand why Gov. Paul LePage has resisted the expansion and refused federal money to fund it.

Under the ACA, the federal government has pledged to cover states’ Medicaid expansion costs completely for the first three years and then scale down funding to 90 percent over the course of several years.

“I think it should have been accepted, there’s money there that’s already [assigned] to the state of Maine for this,” said John, who asked that only his first name be used out of fear of political reprisal. “It’s crazy to dismiss it and throw it away. I don’t know what the point is.”

LePage has argued that the state should not trust the federal government’s promises and that the expansion would end up costing Maine an additional $150 million in each biennial budget, starting in three years.

Many individuals in the coverage gap blame the federal government for their predicament, but Maine could resolve the situation by accepting the federal funds to expand Medicaid, said Sara Gagne-Holmes, executive director of Maine Equal Justice Partners and a lead organizer of Cover Maine Now, a coalition pushing for the expansion.

Maine lawmakers are expected to take up the Medicaid expansion again in January. There is no deadline for states to expand Medicaid, and a few states are still considering it.

The number of uninsured adults who fall into the coverage gap nationally ranges from more than 1 million in Texas to 17,000 in Alaska and Wyoming, according to the Kaiser report.

Many individuals in the coverage gap work low-wage jobs or are employed less than full time due to health conditions, Gagne-Holmes said. Some may see their health conditions worsen without coverage, including people who won’t be able to afford their prescription drugs, she said.

“There’s been so much buildup to the Affordable Care Act starting Jan. 1, then all of a sudden they’re looking for coverage and finding they’re not eligible for Medicaid or even for subsidies in the [marketplace],” Gagne-Holmes said.

Cover Maine Now’s estimate of Mainers who fall into the coverage gap tops the Kaiser figure. According to the coalition, expanding Medicaid would benefit 26,000 childless adults already waiting for Medicaid in Maine, plus another 10,000 who are covered now under a special arrangement that expires at the end of the year, for a total of 36,000.

LePage has argued that MaineCare, Maine’s Medicaid program, is already financially unsustainable and should prioritize the elderly and other vulnerable populations over the childless adults who would benefit from the expansion.

I'm the health editor for the Bangor Daily News, a Bangor native, a UMaine grad, and a weekend crossword warrior. I never get sick of writing about Maine people, geeking out over health care data, and...