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Ashley Tagert didn’t know her family might gain health coverage from the health law—or that the Supreme Court decision could wipe that away.

Tagert, 28, and her husband live in Pearl, Miss., just east of Jackson, on the $2,224 a month that her husband earns as a mechanic. It’s too little, she says, to buy health insurance.

A lifelong migraine sufferer, Tagert has ended up in hospital emergency rooms several times because she couldn’t afford $200 a month for medication that helps ward them off. Just one trip to the emergency room left Tagert $10,000 in debt, helping propel Tagert, her husband and three children into bankruptcy.

Families like Tagert’s were among those that Democrats targeted in the 2010 health overhaul. But Tagert may end up without any health coverage even after the law takes full effect in two years. That’s because the U.S. Supreme Court ruled that states can decide to forgo without penalty a key plank of the law that expanded the federal-state Medicaid program to include all legal residents living in or near poverty.

Republican leaders in some states, including Mississippi, are warning that opting into the expansion is too expensive since the states eventually will have to pay10 percent of the cost for the new program participants.

Nationally, 17.8 million Americans without insurance earn at or below the federal poverty level, which this year is $11,170 for an individual and $23,050 for a family of four. In Mississippi, 53 percent of the people lacking health coverage fall into this group, a bigger portion than in any other state, according to  from the Urban Institute, a Washington-based think tank.

Families can be earning below the poverty line even if one spouse is working full-time, says Edwin Park, vice president for health policy at the Center on Budget and Policy Priorities, another Washington research group. Someone earning the federal minimum wage of $7.25 for 35 hours a week, 50 weeks a year would earn $12,688, which is below the poverty line for any couple with at least one child, he said. 

“If you’re at federal minimum wage, a single earner, two-parent family but only one’s working, you could see how that they could stay under the poverty line,” Park adds.

At least four of 10 uninsured people were below the poverty line in 28 states, including Alabama, Indiana, Idaho, Kansas, Louisiana, Michigan, Ohio, South Carolina, South Dakota and Wisconsin—all states that, like Mississippi, had asked the Supreme Court to overturn the law. Out of the 17.8 million uninsured people at the poverty level or below, Urban estimates 11.5 million would be able to gain insurance through the Medicaid expansion; the others either are already eligible but not enrolled.

“If you don’t expand Medicaid, but you have the other changes [in the health law], the people who are really falling through the cracks are the needier, sicker patients who will become very burdensome to the health care system,” says Dr. Jasmin Chapman, executive director of Jackson-Hinds Comprehensive Health Center, a community health center in Jackson that treated 18,000 uninsured patients last year.

Expanding Mississippi’s Medicaid program would “damage this budget beyond repair” and require deep cuts to education and transportation, Republican Gov. Phil Bryant said after the court ruling.  State Rep. Sam Mims, the Republican chairman of the House Public Health and Human Services Committee, agreed. “We cannot afford to expand Medicaid, and we are going to do everything we can for that not to happen,” Mims told the Associated Press.

Mississippi expects to spend about $822 million on its existing Medicaid program, which is roughly 15 percent of its annual revenue, according to budget documents from the governor’s office. Expanding Medicaid would increase the amount Mississippi spends on the program by 4.8 percent, according to the  (Kaiser Health News is an editorially independent program of the foundation).

If the state decides not to expand Medicaid, some adults earning slightly above the poverty line would be able to get federal subsidies to buy private insurance through another part of the health law designed for lower income people who are not completely destitute. But about 183,000 Mississippi adults at the poverty line or below would have no new options, according to Urban’s estimates.

Chapman says that a large portion of her uninsured patients work, but their employers either do not offer them insurance or the premiums are unaffordable. Many have low-income jobs or work part-time and do not qualify for insurance. “They make just enough so that they can’t get on Medicaid, but too little to buy insurance, so normally what they’ll do is use the ER,” which is much more expensive, she explains. Expanding Medicaid, she says, would allow the state to “save that money and have a healthier and better workforce.”

Angel Greer, who runs the Coastal Family Health Center, a group of community health clinics around Biloxi, adds that many of her uninsured patients lost their jobs in the recession and their health insurance along with it. Others are in coastal industries that don’t provide insurance coverage, including tourism, small local restaurants, manual labor, construction and fishing. 

Her clinics offer medical care on a sliding scale, but finding specialists willing to treat the sicker patients is difficult. Right now they’re “begging local specialty physicians or referring patients to the university hospital in Jackson, which is overwhelming” the hospital, Greer explains.

Roy Mitchell, executive director of the Mississippi Health Advocacy Program, argues that expanding the state’s Medicaid program would be a boon to the state by bringing in more federal dollars. “It’s a huge economic driver, but it’s not recognized as such,” says Mitchell. “It’s almost like there’s this denial.”

Mississippi has one of the smallest Medicaid programs in the country. It covers children of lower income families, including the Tagert’s three kids. But an adult with children can’t earn more than 44 percent of the poverty level, about $6,472 a year for a family of two. Childless adults cannot get Medicaid coverage under any circumstances.

“In Mississippi, we’re the poster child of the dire situation in health care,” says Greer.

“Basically, if you’re a poor adult in the state of Mississippi, you’re on your own.” Many of her patients have left for other states where they are eligible for Medicaid, she adds.

Ashley Tagert, who is studying accounting at a local community college, says her husband’s employer offers health insurance, but the policy would cost them $1,100 a month—about half of their monthly income.

Two months ago, she had a migraine headache that was so severe she lost her vision while driving on the Interstate highway. She’s back on her medications, but the cost burden has led the family to fall behind on utility bills. “It’s a lot of money all at once,” says Tagert.  “We’ll wait and put our gas or light bill off if it’s due when I have to go to the doctors.”

She says they’ve cut down on their clothing and entertainment expenses, but “school’s coming up in August, and we have to buy school supplies. We’re buying them a little bit at a time.”

Tagert says she’s undecided on the federal health law, but she thinks the state ought to expand Medicaid. “I understand that a lot of people might abuse Medicaid,” she says, but not expanding the program “is punishing people like us, even though we’re trying to make a better life.”