Last week I calculated that more than 4 million women could be left uninsured if their governors decide to opt out of expanding Medicaid as part of the Affordable Care Act, as many of them are indicating. But there are subsets within that number that are particularly vulnerable and who were expecting the most help from the ACA. Low-income women who are nearing retirement age could really feel the squeeze, just at a time when they should be focused on storing away money for a comfortable retirement.

A report from The LDI Health Economist site out of the University of Pennsylvania says that under the ACA’s original form when it was passed, “uninsured low-income 55- to 64-year old women were among those who would benefit most from the expansion of Medicaid to cover people with incomes up to 133 percent of the poverty level.” As it reports, there are 27 million women who fall into this category, i.e., women who are “near-elderly” and making little income, and about 14 percent of them are uninsured. A third would have been covered by the Medicaid expansion in all fifty states, or more than 1.2 million. (Another 1.8 million are eligible for the insurance exchange subsidies.) If the Medicaid expansion were to go full steam ahead across the country, the overall rate of uninsured women in this group would be reduced to two percent from the current 11.7 rate.

But that number is in danger if Republican governors like Rick Scott and Rick Perry wriggle out of the expansion. Texas, Florida and Virginia combined have more than 468,000 uninsured women in this category, nearly 160,000 of whom would be eligible for Medicaid. And as the report notes, “A ‘disproportional number’ of these women are reported to be African American and Latino.”

This is a highly vulnerable group of people to begin with. Dylan Roby, an assistant professor at the UCLA Fielding School of Public Health, told LDI that these women are more likely to have chronic illness than the rest of the population. Compared to everyone else, this group “disproportionately really needs preventive care.” On top of this, the report notes, “other research confirms these women suffer higher levels premature death than insured women of their same age.” 

But if they’re on their husband’s insurance plan and he retires, they face a gap in which they can’t themselves go on Medicaid until they catch up to him in age and reach 65. The same scenario plays out if their husbands pass away or they get divorced. This insurance gap can last a whole decade before they qualify for Medicaid, and as they are already low-income, they usually can’t afford individual insurance plans or the medical services they desperately need in the meantime.

Meanwhile, they are usually more financially vulnerable than their male counterparts and therefore will have a harder time paying for medical costs. Even before they qualify for Medicaid at age 65, IWPR has found that overall women ages 62–64 have less money coming in from all sources than men: $333 less in Social Security payments, $555 less in assets, $3,434 less from pensions and a whopping $19,844 less in earnings. There’s that pesky gender wage gap: it compounds by age, but also trickles into other areas, since Social Security benefits and pensions are often calculated or laid away based on wages earned over a lifetime. Women, who on average make less, will get lower payments. That means women have far less income to cover medical expenses while uninsured, even as they need care more than ever.

These struggles will only make it harder for them to store away funds for a quickly approaching retirement. As Teresa Ghilarducci wrote in this weekend’s New York Times, the picture for all Americans is extremely bleak: three-quarters of Americans nearing retirement age have less than $30,000 in their retirement accounts, yet to maintain our living standards we need about twenty times our annual income in financial wealth to get us through. Yet women have far less stored away for retirement than men: only a third have at least $20,000 in stocks, bonds and mutual funds, whereas four in ten men do. Less than half of women have at least $20,000 in a retirement account. IWPR’s numbers on income disparities get far worse by the time women hit retirement age: men ages 65–74 bring in $3,135 more from Social Security, $1,200 from assets, $4,590 from pensions and $9,193 from earnings than women of the same age. 

As Richard Kim spelled out quite clearly last week, the decision not to expand Medicaid really doesn’t have to do with state finances. There are plenty of ways to pay for the relatively small amount of money states will eventually have to kick in. Conservative governors are simply placing a higher priority on other things—mainly tax cuts. But they do so at the expense of millions of women’s health insurance, and in particular at the expense of financial security for thousands of older, low-income women.

Read more on how governors’ refusal to expand Medicaid will impact women. And here are seven infographics demonstrating that those governors really don’t have state finances as an excuse!