JEFFERSON CITY, Mo. — Republicans in at least four states want to abandon an expansion of Medicaid in President Barack Obama’s health-care overhaul, and more than a dozen other states are considering it in the wake of the Supreme Court decision removing the threat of federal penalties.
The high court upheld most of Obama’s law, but the justices said the federal government could not take away states’ existing federal Medicaid dollars if they refused to widen eligibility to include adults who are only slightly above the poverty line. Some Republican governors and lawmakers quickly declared that they would not carry out the expansion.
The states considering whether to withdraw from the expansion include presidential battlegrounds Florida, Ohio, Pennsylvania and Colorado.
“One thing is clear, state legislatures will play a big role in the future of Obamacare,” said Republican state Rep. Todd Richardson of Missouri.
For elected officials, the high court decision presented a choice: agree to accept an ambitious expansion of Medicaid or leave behind federal money that could provide health careto millions of poor constituents.
The law signed by Obama in 2010 was projected to provide coverage to more than 30 million Americans, reducing by more than half the number of uninsured people. Of those, about 17 million were supposed to be added to Medicaid, the joint federal and state healthcare program for the poor. The rest were to be covered by a strengthened and subsidized private insurance market.
The federal government agreed to pay the full tab for the Medicaid expansion when it begins in 2014. But after three years, states must pay a gradually increasing share that tops out at 10 percent of the cost. That translates to a commitment of billions of dollars at a time when many local officials are still anxious about the slow economic recovery.
In Texas alone, where onequarter of the population is uninsured, the Medicaid expansion is projected to provide coverage to 2 million people in the first two years alone. Over a decade, the Texas Health and Human Services Commission estimates that the expansion would cost the state an estimated $27 billion.
Mississippi, which is one of the poorest states in the nation and has more than 640,000people on Medicaid, could cover an additional 400,000 people if it chose to expand Medicaid. But doing so would cost about $1.7 billion over 10 years and force deep cuts to education and transportation, state officials said.
“Mississippi taxpayers simply cannot afford that cost, so our state is not inclined to drastically expand Medicaid,” Republican Lt. Gov. Tate Reeves said.
Republican Nebraska Gov. Dave Heineman promised to block any effort to expand Medicaid, which he said would require tax increases or education cuts. And Indiana Senate President Pro Tem David Long, also a Republican, asserted that his state “will certainly” opt out of the Medicaid expansion.
The expansion was also quickly rejected by Republican legislative leaders in Missouri, where 255,000 of the state’s roughly 835,000 uninsured residents stood to be added to the program. In 2005, Missouri slashed its Medicaid eligibility for parents to the lowest levels allowed by the federal government to help balance the budget. The expansion in Obama’s health-care law would restore coverage to those people and add many more. The cost: $2 billion annually, of which Missouri would pay about $100million beginning in 2017, with its share rising above $150 million by 2019.
In states that reject the Medicaid expansion, some lower-income residents who work could find themselves in a coverage gap between the extremely poor and the middle class. The health-care law offers tax breaks to offset the cost of private insurance purchased through new online marketplaces for those whose incomes are above the poverty level. But there are no breaks for many others who earn below the poverty level but still aren’t considered poor enough to receive Medicaid. The law assumed they would be covered by an expanded Medicaid program.
Some states have already expanded Medicaid eligibility beyond the standard set in the federal health-care law. Others are forging ahead with plans to do so after the Supreme Court ruling.
Minnesota, for example, has already begun drawing more federal money to expand its Medicaid program ahead ofschedule. Officials in Connecticut, Iowa and elsewhere said they will move forward with plans to raise their Medicaid income eligibility thresholds, citing the chance to cover hundreds of thousands of additional people with most of the cost coming for the federal government.
Despite the reluctance of some state officials to embrace the Medicaid expansion, history suggests that the federal government’s financial carrot can be a powerful incentive. When the federal government offered enhanced payments to expand health coverage for children in the 1990s, all states eventually implemented the program, said Jennifer Tolbert, director of state health reform at the Kaiser Family Foundation, a nonpartisan informational clearinghouse.
Information for this article was contributed by Chris Blank, Jamie Stengle, Emily Wagster Pettus, Grant Schulte, Charles Wilson, David Pitt, Chuck Bartels, Susan Haigh, Barry Massey, Marc Levy, Gary Fineout and John Seewer of The Associated Press.
Front Section, Pages 2 on 06/30/2012