Letharius Smith hadn't seen a doctor in years.
He didn't have a job or insurance, so he went without even basic medical care. Or he did until his tooth got infected so badly he was in constant pain, his face was swollen and he could only chew on one side of his jaw. Smith ended up at the St. Petersburg Free Clinic.
"Because of this tooth incident, it made me think I can't do this anymore," Smith, 27, said.
Smith knows nothing about Obamacare or the debate in Florida about whether to expand Medicaid.
But he's a prime example of one of the most complicated aspects of the new health care law.
While the law requires almost every Floridian to receive some type of health insurance and offers generous subsidies to help people with lower incomes, Smith and 1 million other Floridians fall into a black hole of insurance coverage.
Because of a split ruling from the U.S. Supreme Court and a decision of the Florida Legislature, 1 million poor Floridians will not qualify for government-managed Medicaid or any tax subsidies to purchase health insurance on their own starting next year.
That means Smith, who lives with his girlfriend (who is employed) and their three children, will enter 2014 the way he exits 2013 — without the hope of having health insurance.
It wasn't intended to be this way.
The health care law that passed Congress and was signed into law by President Barack Obama attempted to provide low- and middle-income earners health insurance in one of two ways: Some would be sent into the private market and offered subsidies; others would be funneled into Medicaid.
But the Supreme Court, in its landmark decision upholding the health care law, also ruled that the federal government could not force states to expand their Medicaid programs.
This year, Florida chose not to. House Republicans also blocked a plan supported by Gov. Rick Scott and Republicans in the Senate to use $51 billion in federal funding to allow people in positions like Smith's to purchase private policies.
As a result, Smith remains on his own.
Florida is among 22 states that did not expand Medicaid to cover people making up to 138 percent of poverty, or about $38,000 for a family of five. Although Democrats and advocacy groups continue to push for Medicaid expansion, they don't appear any closer to compromise with Florida's Republican leaders.
Under the existing rules, parents and young adults can't qualify for Medicaid if they make more than 22 percent of the poverty level, or about $2,500 a year for a single adult and about $5,200 for a family of four. Children may receive Medicaid.
Childless adults 21 or older can't receive Medicaid at all.
But the subsidies to help people afford private insurance don't kick in unless they earn between $11,490 and $46,000 each, which is 100 to 400 percent of the poverty level.
What's in between? One million people.
"The people who need help the most will be at least temporarily excluded unless and until Florida decides to opt into the Medicaid expansion," said Ron Pollack, executive director of Families USA, a national organization supporting implementation of the law.
(People who fall in the coverage gap are exempt from a penalty for not purchasing health insurance.)
Uninsured Floridians often turn to local health departments or community health clinics for medical care, paying little or nothing for these services. But specialized care for serious illnesses and injuries often falls outside the clinics' scope.
Besides, Pollack said, many uninsured people avoid seeking medical attention until their problems worsen because they are afraid they cannot afford it.
"So they often don't get checkups or other preventative care," he said. "At the onset of pain or a disease, they often wait and hope that it's going to go away. And, as a result for many people, they wind up having health problems that could have been avoided."
The other option for the uninsured is the one that nearly everyone agrees is both costly and inefficient: hospital emergency rooms. Hospitals in Florida say they will continue to treat patients regardless of their ability to pay, even if it means higher costs for them and longer waits for patients.
"There is really nowhere for those people to turn," said Tony Carvalho, president of the Safety Net Hospital Alliance of Florida. "They are the charity cases that we care for now, and they'll remain that way."
Safety net hospitals, though, are bracing for reductions in federal funding they currently receive for serving needy patients. The health care law assumed Medicaid expansion would eliminate much of the problem.
"Clearly there are cuts taking place," Carvalho said. "How they implement it, there's still not all the details finished on that. But they're big (the cuts)."
Shortly after the Supreme Court ruled that Medicaid expansion was optional for states, the Urban Institute, a social policy research group, estimated how many people would remain uninsured if states decided to do nothing.
Using data on health care coverage and income levels, the institute estimated that 995,000 Floridians stood in the coverage gap.
"For poor individuals, gaining Medicaid coverage will allow them to have better access to affordable health care and reduce the financial burdens that they experience associated with meeting their health care needs," said Urban Institute senior fellow Genevieve Kenney, one of the authors of the report.
Three states are still deciding whether to expand Medicaid; 22 have said "no" and 25 have said "yes." Most Republican-controlled states opted out, but there are some outliers: Arizona, Michigan and North Dakota.
The split among states may be what ultimately causes Florida lawmakers to change their minds and expand Medicaid, Carvalho said. When Medicaid expansion and the billions of dollars in associated federal funding begin on Jan. 1, Florida will watch as other states close their coverage gaps and reap the benefits, he said.
"I think it becomes more real once the coverage is expanded in those states that have chosen to do that," Carvalho said. "And there will be some comparisons that can be made with individuals, with real people, with real families."
Times staff writer Jodie Tillman contributed to this report. Tia Mitchell can be reached at [email protected]