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Imagine a country where some of its low income citizens are covered by public health insurance and some not.  Not because of age, color, religion, gender or the like.  But simply due to where they happen to live.  That could be the future in the U.S.  

The immediate problem is the Supreme Court's decision that the federal government cannot threaten states with the loss of ALL existing Medicaid funding if they do not accept the Medicaid exansion in the ACA.  Not, ALL.  The court did not address the issue of whether the federal government cann withhold SOME of the existing Medicaid funding if the state does not participate.  Whether such a change could be done by regulation as opposed to legislation is a seperate issue.

The long-term problem is that Medicaid is a joint federal-state progam.  Apparently this is so because Medicaid came in with Medicare.  And the framers were concerned about the political opposition to the cost if both were exclusively federal programs.  What we need, of course, is Medicare for all, regardless of age or income.  Make the entire health insurance system, or at least the entire public health insurance system, federal.  What we know, unfortunately, is we're to going to get that any time soon due to the intense political opposition to even the moderate ACA changes.

Robert Pear discussed the lastest Medicaid development:

Millions of poor people could still be left without medical insurance under the national health care law if states take an option granted by the Supreme Court and decide not to expand their Medicaid programs, state officials and health policy experts said Friday.

Republican officials in more than a half-dozen states said they opposed expanding Medicaid or had serious doubts about it, even though the federal government would pick up all the costs in the first few years and at least 90 percent of the expenses after that.

. . . .

But already, 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.”

http://www.nytimes.com/...

Yeah, the flexibility to use the money on things other than its intended purpose.

But the reason they won't take it has nothing to do with the relatively modest cost, which won't kick in for several years.  It's because they don't care about low income people going without insurance, or they just want to spite Obama.  Or both.

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Comment Preferences

  •  Tip Jar (20+ / 0-)

    “The country tried everything Romney says, and it brought the economy to the brink of collapse”

    by Paleo on Sat Jun 30, 2012 at 06:29:25 AM PDT

  •  Obamacares - Republicans don't. (9+ / 0-)

    "Tax cuts for the 1% create jobs." -- Republicans, HAHAHA - in China

    by MartyM on Sat Jun 30, 2012 at 06:34:10 AM PDT

  •  I had thought the only think (1+ / 0-)
    Recommended by:
    glorificus

    Nikki Haley was actually good at was shoving.

    Have you heard? The vice president's gone mad. - Bob Dylan, 1966

    by textus on Sat Jun 30, 2012 at 06:49:38 AM PDT

  •  The ad campaign writes itself. Because the (11+ / 0-)

    Medicaid expansion expands it into THE MIDDLE CLASS.  Hardworking men and women supporting families are deliberately being cut off access to health care out of spite.

    There are politicians WAITING to unleash that campaign.

    "Nothing in all the world is more dangerous than sincere ignorance and conscientious stupidity." --M. L. King "You can't fix stupid" --Ron White -6.00, -5.18

    by zenbassoon on Sat Jun 30, 2012 at 06:53:01 AM PDT

  •  They will never got through with it. (1+ / 0-)
    Recommended by:
    glorificus

    They are all afraid of getting primaried from the right on this.

    So I see only tatters of clearness through a pervading obscurity - Annie Dillard -6.88, -5.33

    by illinifan17 on Sat Jun 30, 2012 at 06:56:24 AM PDT

  •  Are the federal funds needed for the transitional (1+ / 0-)
    Recommended by:
    FiredUpInCA

    support to the expanded state medicaid already in place?

    If not, this is a major vulnerability of our program, as the House Republicans have already indicated their intent not to fund it.  And, even progressive blue states are not in a position to provide for the funding of those whose incomes are below the penality threshold, which I seem to remember was set at 400% of the poverity level.  

    We need to get to work focusing on these implementation details because the GOP is going to exploit every opportunity to undermine the APA's success.  And, then blame Democrats for any failure.  

    Do I remember correctly that most of the additional coverage for the 39 million people we intend to add to covered population is expected to come from these expanded state medicaid coverage?    

    The means is the ends in the process of becoming. - Mahatma Gandhi

    by HoundDog on Sat Jun 30, 2012 at 06:56:58 AM PDT

    •  Separate things (3+ / 0-)
      Recommended by:
      glorificus, kayebee, HoundDog

      The penalty has nothing to do with the Medicaid expansion.  Which covers up to 133% of the poverty level.  I'm not sure of the figures of how many will be covered by the Medicaid expansion and how may will be covered if they purchase subsidized coverage.

      “The country tried everything Romney says, and it brought the economy to the brink of collapse”

      by Paleo on Sat Jun 30, 2012 at 07:01:54 AM PDT

      [ Parent ]

      •  I thought the Medicaid expansion was our coverage (0+ / 0-)

        plan for those up to 400% of the poverty level.  

        Because the "federal assisstence" to those that can not afford to buy full health care policy is in the form of tax credits, which do no good for those that don't owe the $7,000 or more it would take to get a family policy.

        So, my understanding is that our APA coverage plan for those families earning less than $60,000 has been these state based Medicare expansions to include those up to 400% of the poverty level.

        This would appear to be a substantial fraction of those not currently covered.  

        There are some "free-riders" who can afford coverage but decide not to get it, but this is not the majority, by my understanding.

        So, if substantial numbers of states opt-out we would seem to have a large hole in our coverage plans.  But, at least, we will generate the hard data, and be able to focus news coverage on the fact that it is the GOP who are denying these Americans the health coverage they would get, if they lived in other states.  

        My thought is why wait for these people to suffer, and our plan to appear to be in shambles?  Could we get proactive enough to put a pre-emptive full court press on the obstructionist GOP politicians who would be resonsible for keeping vast numbers of middle class and poor citizens off of our ACA coverage plan?

        The means is the ends in the process of becoming. - Mahatma Gandhi

        by HoundDog on Sat Jun 30, 2012 at 01:01:47 PM PDT

        [ Parent ]

        •  Firstly, the Medicaid expansion is up to (1+ / 0-)
          Recommended by:
          HoundDog

          133% of poverty. The 400% is for the exchanges.

          Secondly, the tax credits get figured into your paycheck. If you have one, of course.

          Free riders in Massachusetts are about 1% of the population.

          You are correct about holding the Right's feet to the fire in states that opt out. Hospitals and doctors will be furious, and even some ordinary citizens understand that covering the poor saves them money, either in taxes or insurance payments, that currently goes to ER expenses. Some might even notice that the Medicaid expansion will stop the 20-year slide in the number of ERs.

          Hands off my ObamaCare[TM]

          by Mokurai on Sat Jun 30, 2012 at 01:40:38 PM PDT

          [ Parent ]

  •  At low incomes exchange policies (2+ / 0-)
    Recommended by:
    DRo, Losty

    will be highly subsidized.

    Surely, somebody in a Rabidly Republican Red state at 134% of FPL won't have to shell out thousands for exchange coverage while somebody in a Blue state at 132% of FPL gets Medicaid coverage for free.

    •  for a 53-year old with a $16,000 income (3+ / 0-)
      Recommended by:
      davehouck, DRo, Mokurai
      Note: Subsidies are only available for people purchasing coverage on their own in the Exchange (not through an employer)....

      Projected income in 2014  
      $16,000     139% of poverty

      Unsubsidized health insurance premium in 2014 adjusted for age
      $7,826
      (Based on an age factor relative to a 40 year-old of: 1.74)

      Maximum % of income the person/family has to pay for the premium if eligible for a subsidy
      3.36%

      Actual person/family required premium payment
      $537  
       (which equals 3.36% of income and covers 7% of the overall premium)

      Government tax credit
      $7,289  
       (which covers 93% of the overall premium)

      Out-of-Pocket Costs  
      The maximum out-of-pocket costs the person/family will be responsible for in 2014 (not including the premium) is $2,083. Whether a person or family reaches this maximum level will depend on the amount of health care services they use. Currently, about one in four people use no health care services in any given year.
      The guaranteed plan for the person/family will have an actuarial value of 94%.

      http://healthreform.kff.org/...
      •  A question ... (0+ / 0-)

        This is a tax credit, does that mean that I would have to pay the premieum upfront and then get a tax credit that cuts my taxes or would it be something more like an earned income credit that gives you a refund?  And what happens when you can't pay the insurance upfront and wait for the credit/subsidy? Do you then go uninsured and pay the penalty?

        I am soooooooooooo confused!

        "Life without liberty is like a body without spirit. Liberty without thought is like a disturbed spirit." Kahlil Gibran, 'The Vision'

        by CorinaR on Sat Jun 30, 2012 at 07:32:54 AM PDT

        [ Parent ]

      •  The exchange premiums (0+ / 0-)

        and out-of-pocket maximums vary by income, not by age.

        The exchange premiums and out-of-pocket maximums would be the same for a 28-year old and a 55-year old.

    •  for $15,500, 135% of FPL (1+ / 0-)
      Recommended by:
      davehouck
      Actual person/family required premium payment

      $481

      (which equals 3.10% of income and covers 6% of the overall premium)

    •  for various incomes (0+ / 0-)

      the percentage of income for premium and the dollar amount of the premium on an exchange for a single person

      $15,500 3.10% $481
      $17,000 3.87% $658
      $20,000 5.10% $1,019
      $25,000 6.91% $1,726
      $30,000 8.36% $2,509
      $35,000 9.50% $3,325

  •  Yes, And Imagine Democrats Defeating Republicans (5+ / 0-)

    who blatantly lie and use a political argument to deny healthcare to the most vulnerable, (who will be made more vulnerable as the result of Republican policies), like Governor  Dave Heineman of Nebraska, who claims the expansion is quote "unfunded," when it's actually 100% funded until 2016 and funded up to of 90%, in, 2019 and thereafter.  

    The law calls for the federal government to pick up all the costs of the Medicaid expansion from 2014 to 2016. After that, states would gradually start having to pay a portion, but the federal government’s share would not fall below 90 percent.   source:
    Add blatant lying to the fact that Republicans claim public education and other social services will have to be cut, when Republicans everywhere have been gutting public education and the social safety net, with abandon, anyway.  
  •  From what I gather (1+ / 0-)
    Recommended by:
    FiredUpInCA

    the biggest effect of Republican Medicaid expansion refusals on patients will be out-of-pocket payments for medical care.

    Going to the doctor will mean the poor paying out of pocket up to around $2,000/year.

    For the federal government, higher exchange subsidy payments will be required which mean across the board federal budget cuts due to the debt deal.

    For providers, the exchange carriers will pay more for poor than Medicaid, but often not cover them for the first $2,000 or so.

  •  it's their loss and that of their constituents... (4+ / 0-)
    Recommended by:
    FiredUpInCA, kayebee, Losty, 3goldens

    Robert Reich was on one of the talk shows last night (either the Ed Show or Rachel Maddow, don't remember which). And he, basically, said it doesn't matter that much whether these Republican governors do anything because, sooner or later, they are going to have to explain to their constituents why they have denied them the same basic health care coverage that citizens in other states enjoy. At some point in time, they will realize that and hold these Republican dinosaurs accountable.

    •  Forcing the federal government (1+ / 0-)
      Recommended by:
      wdrath

      to pay 94% or more of the exchange premiums is better than allowing the federal government to pay only 90% for Medicaid in the long term.

      Also since more patients will be market rate customers than lower Medicaid provider pay rate under Medicaid expansion, the market rate can be lower for the same provider costs. The massive federally 94% subsidized market rate provider payments will save the great middle class of our great state a great deal of money [at federal expense].

      If the damned DC Democrats have to sacrifice waste in DC to pay more for exchange premium subsidies in our great state, so much the better. Better the money here than in DC.

      Also, when loyal Democrats are smacked with a Democratic penalty "tax" under a law passed by Democrats which they refused to repeal despite my pleas, then it is good for Republican politicians like me.

          Wacky Wingnut, Republican Governor

  •  It would cost them healthcare jobs to turn it down (4+ / 0-)
    Recommended by:
    FiredUpInCA, kayebee, Losty, luckylizard

    Hospitals in those states would still be legally required to provide emergency care at emergency rooms but they would not get reimbursed by Medicaid like hospitals in states that did take the money.

  •  I doubt it. (1+ / 0-)
    Recommended by:
    Losty

    The federal govt covers 90% of the cost (and 100% the first 3 years). The state does face pressure from its citizens to have reasonable funding for Medicare compared to other states. If a government decided to decline the money irrationally (say, Rick Scott, who has done such things) it would really not take long for the electoral process to get rid of the governor.

  •  More precisely, that has been true in the US (0+ / 0-)

    since Medicaid started, and was true of other public assistance programs long before. States have great leeway in setting eligibility requirements, and Red states set the limits as low as they can get away with. See

    GOP governors fight to preserve dismal red state health care

    which gives a map plus links to state-by-state numbers.

    Hands off my ObamaCare[TM]

    by Mokurai on Sat Jun 30, 2012 at 01:22:47 PM PDT

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