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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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