Millions of poor Americans may still be left without health insurance despite the Supreme Court upholding President Obama’s signature legislative accomplishment, the Affordable Care Act. The Supreme Court ruling did not give individuals the option to opt of the law’s mandate but states were granted the option to not expand their Medicaid programs leaving coverage for at least 17 million poor people in limbo.
Republican officials in more than a half-dozen states said they are either opposed to or had serious doubts about expanding Medicaid, regardless if the federal government picks up all the costs in the first few years and covers at least 90 percent of the expenses after that.
In writing the law, Congress assumed that the poorest uninsured people would gain coverage through Medicaid, while some people with slightly higher incomes would receive federal subsidies to buy private insurance. Now, poor people who live in a state that decides to not expand its Medicaid program will find themselves unable to obtain either Medicaid or subsidies.
Under the law, subsidies are available to people with incomes from the poverty level up to four times that amount, but not to people with incomes below the poverty level ($23,050 for a family of four).
Governors in Kansas, Nebraska and South Carolina, among other states, have said they would have difficulty affording even the comparatively small share of costs that states would eventually have to pay.
Gov. Dave Heineman of Nebraska, a Republican who is chairman of the National Governors Association, indicated that he was against expanding Medicaid eligibility.
“As I have said repeatedly, if this unfunded Medicaid expansion is implemented, state aid to education and funding for the University of Nebraska will be cut or taxes will be increased,” Mr. Heineman said.
In South Carolina, Rob Godfrey, a spokesman for Gov. Nikki R. Haley, said, “We’re not going to shove more South Carolinians into a broken system that further ties our hands when we know the best way to find South Carolina solutions for South Carolina health problems is through the flexibility that block grants provide.”
In New Hampshire, State Representative Andrew J. Manuse said he and other Republicans were already working to block the expansion of Medicaid. “We can’t afford it,” Mr. Manuse said. “It’s as simple as that. Thank God the Supreme Court gave us an option.”
Republican governors in Wisconsin and Louisiana said they would wait to see the results of November’s elections before deciding whether to expand Medicaid, in the hope that Mitt Romney will be elected president and undo the health care law. “That’s why we have refused to implement the Obamacare health exchange or the Medicaid expansion,” said Gov. Bobby Jindal of Louisiana.
“Because the expansion is such a good deal for states, they should move forward and cover low-income adults in their states,” said Judith Solomon, a health policy analyst at the Center on Budget and Policy Priorities, a liberal research and advocacy group. “But what happens in states that do not go ahead and provide coverage? The poorest adults — primarily parents and other adults working for low wages — will be left out in the cold.”
Richard J. Umbdenstock, the president of the American Hospital Association, said that hospitals around the country would lobby for the Medicaid expansion. “If states do not avail themselves of this opportunity,” he said, “the federal money will go to other states, and hospitals will be left with large numbers of the uninsured.”
Nancy M. Schlichting, chief executive of the Henry Ford Health System in Detroit, said she “absolutely will lobby” for the expansion of Medicaid. She said she expected Gov. Rick Snyder, a Republican, to support the expansion, but she added, “he may have trouble” getting it through the Michigan Legislature.
Congress has repeatedly expanded Medicaid in the last 25 years, and states often had new sources of revenue, like money from the settlement of lawsuits against major tobacco companies. “But this time is different,” said Dennis G. Smith, secretary of the Wisconsin Department of Health Services. “Virtually all states are struggling to sustain their current Medicaid programs.”
Illinois, facing severe financial problems, has already delayed Medicaid payments to some health care providers.
“Many hospitals are not being paid for six months or more after they provide services and file claims,” said Danny Chun, a spokesman for the Illinois Hospital Association. “Illinois is dead broke.”