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In the wake of the Supreme Court decision in NFIB v. Sebelius, the greatest threat to enabling health insurance for 30 million uninsured Americans may come not from Republicans in Congress, but in the states. With the Court's ruling that the federal government cannot penalize states who refuse to accept the expansion of Medicaid, Republican governors are threatening to turn down $258 billion in funding that would cover roughly 9.2 million Americans. Worse still, as McClatchy reported this week, "Not only might some states opt out of increasing the number of adults in the government health-insurance program for the poor as a result of the Supreme Court's ruling, but they also might cut people who now are enrolled."

Phil Galewitz of Kaiser Health News explained how that nightmare scenario could unfold:

This wasn't supposed to happen under President Barack Obama's health law, which was designed to expand coverage for 30 million Americans, in part by adding 17 million people to Medicaid. But the impact of the Supreme Court's ruling last week making the expansion voluntary is likely to be compounded by another provision in the law that the justices left intact: In 2014, states no longer are barred from making it harder for adults to qualify for Medicaid.

Experts worry that those two developments taken together could spur some states to reduce the number of people covered.

Here's why. Currently, the $300 billion Medicaid program serves roughly 60 million Americans. On average, the federal government picks up 57 percent of the tab, with poorer states like Mississippi and Alabama getting 75 percent of the funding from Washington. Medicaid not only pays for a third of nursing home care in the United States; it covers a third of all childbirths. In Texas, the figure is one half. But with the full implementation of the Affordable Care Act beginning in 2014, federal assistance will increase. The expansion of Medicaid to families earning 133 percent of the federal poverty level (FPL) and the availability of subsidies to those at four times the FPL will enable coverage for over 30 million more people nationwide. (Of these, the Urban Institute estimated that 8.1 million Americans would have their insurance paid for in full by the expansion of Medicaid. Another 10.9 million people would receive subsidies to buy private insurance in the new state exchanges, while only 7.3 million, 2 percent of the total U.S. population, would be required to purchase a health plan using their own resources alone.)

But as New York's former Medicaid director Deborah Bachrach explained, the Court's ruling last week means states could throw some low-income adults "into a black hole with nowhere to turn for coverage." Galewitz provided a potential case in point:

As a hypothetical example, if Mississippi opted out of the 2014 expansion of Medicaid, poor childless adults wouldn't gain coverage in that state. At the same time, the state could roll back eligibility for parents with children who are currently enrolled, reducing the number of participants in the program.
And as Glenn Kessler explained in the Washington Post last year, it is hard to believe that a state like Mississippi could make it current program any worse:
Mississippi provides some of the lowest Medicaid benefits to working adults in the nation. A parent who isn't working can qualify only if annual family income is less than 24 percent of the poverty line. Working parents qualify only if they make no more than 44 percent of the federal poverty level. Seniors and people with disabilities are eligible with income at 80 percent of the poverty line...

Translated from the federal poverty guidelines, that means a working Mississippi couple with one child could earn no more than $8,150 a year and still qualify for Medicaid, seniors and people with disabilities could earn no more than $8,700, and a pregnant woman could earn no more than $20,000 a year.

The new barriers states might erect to health insurance don't end there.

Continue reading below the fold.

"Another way states might choose to minimize their costs is by shifting people who are eligible for federal subsidies to buy private insurance out of the Medicaid program and into the new online markets created by the law," Galewitz wrote, adding, "That saves states money because the federal government pays the entire cost of the subsidies—unlike Medicaid, in which states share in the costs."

As it turns out, those new health insurance exchanges, which the federal government will establish for states like Texas and Louisiana which choose not to, may be tripped up by a glitch in the text of the Affordable Care Act. As TPM revealed:

Because as the result of a drafting oversight, Congress neglected to include automatic appropriations for federally facilitated exchanges (FFEs). That means there's money on hand to help states that want to set up the exchanges themselves, but the government's options vis-a-vis states that can't or won't act on their own are more limited.

Thus far, HHS has provided exchange establishment awards to 34 states. But the Kaiser Family Foundation lists over a dozen states that have either made no progress toward setting up exchanges or have announced they don't intend to comply with the ACA. And if conservatives have their druthers, states that have already received grants will be pressured to return them.

If Republican-led states react to the Court's decision by digging their heels in deeper on the exchanges, rather than by relenting, the federal government will face significant challenges. Though HHS has made some progress creating the federal exchange architecture, it's likely to run into financial and logistical obstacles.

And that gives Republican governors a trump card to play in pushing Congress to loosen eligibility requirements or demanding Medicaid funds as block grants turned over to the states. (As recent history shows, governors would take advantage of block grant status "by capping enrollment, thinning benefits, increasing co-payments, and so on.") So even if Senate Minority Leader Mitch McConnell doesn't succeed in his quest to "repeal Obamacare, one way or another" in Washington D.C., his GOP allies in the states may prevent the law from helping millions of Americans the Affordable Care Act was designed to serve.

Originally posted to Jon Perr on Thu Jul 05, 2012 at 11:17 AM PDT.

Also republished by Daily Kos.

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Comment Preferences

  •  This is true (4+ / 0-)

    And if state-level GOP officials want to continue to block and/or roll-back coverage for their citizens at a local level, all while people in other states ARE receiving those benefits, then I for one will eagerly look forward to the Democratic Party controlling Statehouse Legislatures and Governor Mansions in well over 75% of the country in the near future.

    Please, please Governor and State Senator Wingnut: Don't throw us into that briar patch.

    Красота спасет мир --F. Dostoevsky

    by Wisper on Thu Jul 05, 2012 at 11:33:21 AM PDT

  •  It seems to me this should be (4+ / 0-)

    an easy campaign issue for Democrats to use. It should not be difficult at all to point at every uninsured American and blame it squarely on Republican ideology since Democrats have provided that insurance and the only reason they are not receiving it is that Republican Governors are blocking it.

    That one should not be tough to sell and it will not be only minorities suffering but many Republican voters as well.

    "Do what you can with what you have where you are." - Teddy Roosevelt

    by Andrew C White on Thu Jul 05, 2012 at 11:34:07 AM PDT

    •  Not easy. (5+ / 0-)

      What's easy is saying: He said you would be insured! He said it would lower costs!

      It's like pointing to the bad economy now and crying "The Republicans sat on their hands in Congress and did NOTHING about jobs and stood in the way of every job program".

      When you are in charge and you make promises, blaming a failure on saboteurs is actually quite difficult, even when, as here, it will be true.

    •  Assuming Dems choose to run w/ this issue (5+ / 0-)

      Kathy Hochul's response to the political gift that GOP nominee Chris  Collins recently tried to give her makes me wonder a little:

      "People now don't die from prostate cancer, breast cancer and some of the other things," he told The Batavian in an interview that was flagged Tuesday by City & State NY. Collins was discussing his desire to repeal Obamacare. "The fact of the matter is, our healthcare today is so much better, we're living so much longer, because of innovations in drug development, surgical procedures, stents, implantable cardiac defibrillators, neural stimulators — they didn't exist 10 years ago," he continued. "The increase in cost is not because doctors are making a lot more money. It's what you can get for healthcare, extending your life and curing diseases."

      Luckily, his Democratic opponent, one Kathy Hochul, stepped up to the plate and knocked this fat, hanging curveball for a solid, five-bounce infield hit....

      Hochul said Monday that she knows the president's signature health care law is imperfect, but Congress needs to address other issues. "There's a lot of uncertainty about this, but it is now the law of the land and they understand that," she said at a town hall in Victor, N.Y., according to local NBC affiliate WHEC.com. "And we don't want to take this country backward and re-litigate and re-fight over this. We've got a lot of other issues to deal with. We've got an economy that has to get back on track."

      in the same vein, today's LA Times contained a fascinating factoid:
      Over the past 20 years, Republican presidential candidates have averaged 44.5% of the popular vote in presidential campaigns; Democratic candidates have averaged 48.4% (third party candidates account for the rest).
      Given how the 2 parties conduct themselves, one might be confused as to which party won the popular vote in 4 of the past 5 national elections and which party lost 4 out of 5.  There's pretty much of a role reversal in terms of self-confidence, pursuing agendas, and attempting to meet the other party "halfway."

      Health care is just one of many issues where this discouraging trend seems to persist.

      Some men see things as they are and ask why. I dream of things that never were and ask why not?

      by RFK Lives on Sat Jul 07, 2012 at 02:24:33 PM PDT

      [ Parent ]

  •  Kind of makes (7+ / 0-)

    that 30 million helped I keep hearing, pretty dubious. What a mess. After this divisive debacle of affordable health care and insurance reform it seems the only real beneficiaries are the for profit insurance companies and the health care industries. So what did we gain? middle class people who can afford the vig and their children cannot be denied insurance. How does that equate to affordable care for anyone? The poor now are screwed if they live in states like Louisiana,  So called middle class people who are self employed or high risk cannot form pools. There are no caps on what they can charge you for juink and yet they .... 'fine you every time you slam the door'

    •  PNHP has link to video which agrees with you.... (5+ / 0-)
      MSNBC's O'Donnell: With single payer, we wouldn’t be in this mess

      Watch host Lawrence O’Donnell explain the “virtually indescribable mess” the compromised federal health law has created, including as it affects women’s health, and why Congress should have enacted a single-payer system. Don't miss this blistering attack on the private health insurance industry and Big Pharma.

      How did the Supreme Court decision on ACA help the 23 million still uncovered? Ask the 18,000 Doctors of [url]http://www.pnhp.org[/url] -- they're not waiting, but working now to pass H.R. 676, the “Expanded and Improved Medicare for All Act .

      by divineorder on Thu Jul 05, 2012 at 11:59:01 AM PDT

      [ Parent ]

      •  Thanks divineorder (3+ / 0-)
        Recommended by:
        divineorder, blueoasis, splashy

        I don't have cable anymore. O'Donnell seems to be on the right side here. I am happily surprised.

        •  YOU need to STFU if you have nothing (0+ / 0-)

          of substance to say and must resort to threats and chest-thumping in defense of 'your guy'. Methinks you react this way because you are threatened by the truth when it comes to Obama and the ACA, and McDonnell's piece was nothing if not a rare gem of truthfulness in the sad public spectable of the national healthcare 'debate'; he masterfully cut right to the essense of the problem that is the ACA.

          Here is the link for those who couldn't find it on the PNHP main page.

          "It depends what the meaning of 'is', is"
          Platform of the Neo-Democratic Party
          Speaking out of one side of their mouth for the little guy, their nominal constituency, and the other for the plutocracy, their real constituency.

          by Sanctimonious on Sat Jul 07, 2012 at 09:19:29 PM PDT

          [ Parent ]

          •  WHOOPS - my comment was intended for wyvern below. (0+ / 0-)

            "It depends what the meaning of 'is', is"
            Platform of the Neo-Democratic Party
            Speaking out of one side of their mouth for the little guy, their nominal constituency, and the other for the plutocracy, their real constituency.

            by Sanctimonious on Sat Jul 07, 2012 at 09:20:28 PM PDT

            [ Parent ]

      •  Lawrence O’Donnell ... (4+ / 0-)

        ..needs to STFU.

        Instead of using his TV show to educate his audience on what is contained in the Affordable Care Act, he bitches about a hypothetical.

        The only “virtually indescribable mess” here is the virtually indescribable mess MSNBC made when they gave this idiot his own TV show.

        I realize Lawrence O’Donnell feels it's his duty to frighten, confuse & depress his audience, but he needs to grow up.

        You want to serve liberals, Lawrence O’Donnell?

        Then stop whining about your single-payer fantasy & begin using your show to educate people on what we have set before us.

        I realize you would think it an abomination to actually use your TV show as a public service devise, but cut the shit & stop acting like one of the worthless kooks on Fixed News.

        Rob not the poor, because he is poor: neither oppress the afflicted in the gate. ~ Proverbs 22:22

        by wyvern on Sat Jul 07, 2012 at 02:17:42 PM PDT

        [ Parent ]

        •  If anyone needs to STFU (0+ / 0-)

          it is you for trying to quiet a lone voice of reason and sanity on national TV regarding the goddawful mess that is the ACA. But tragically, that is all the Obama diehards have left to fight for - belitting and censoring the few remaining progressive viewpoints in the public airwaves whenever they contradict Obama's pov, no matter how right wing. How refreshing and rare to hear someone come right out and call cowdung cowdung and do so from a truly pragmatic progressive pov, on national TV no less.

          I have a right to hear the truth and I will fight against those who try to silence it, no matter what party label they cower under.

          "It depends what the meaning of 'is', is"
          Platform of the Neo-Democratic Party
          Speaking out of one side of their mouth for the little guy, their nominal constituency, and the other for the plutocracy, their real constituency.

          by Sanctimonious on Sat Jul 07, 2012 at 09:09:09 PM PDT

          [ Parent ]

        •  YOU need to STFU if you have nothing (0+ / 0-)

          of substance to say and must resort to threats and chest-thumping in defense of 'your guy'. Methinks you react this way because you are threatened by the truth when it comes to Obama and the ACA, and McDonnell's piece was nothing if not a rare gem of truthfulness in the sad public spectable of the national healthcare 'debate'; he masterfully cut right to the essense of the problem that is the ACA.

          Here is the link for those who couldn't find it on the PNHP main page.

          "It depends what the meaning of 'is', is"
          Platform of the Neo-Democratic Party
          Speaking out of one side of their mouth for the little guy, their nominal constituency, and the other for the plutocracy, their real constituency.

          by Sanctimonious on Sat Jul 07, 2012 at 09:22:57 PM PDT

          [ Parent ]

      •  Should of, could of (2+ / 0-)
        Recommended by:
        ChurchofBruce, LeftyEngineer

        Congress should have gotten everyone a pony as well.
        Had we gone for single payer, we would now be covering people's medical costs with the currency of plantive sighs of how we tried but didn't make it and the sighs:dollar exchange rate is very sucky.

    •  I think the ACA has far too many (2+ / 0-)
      Recommended by:
      splashoil, qofdisks

      moving parts and there's just no way to know how this will all shake out. We needed something far simpler and more predictable than the ACA and I'm afraid it's going to backfire and actually hurt many of those it was intended to help.

      What a clusterfuck!

      Honesty pays, but it doesn't seem to pay enough to suit some people. Kin Hubbard

      by Mr Robert on Sat Jul 07, 2012 at 03:50:34 PM PDT

      [ Parent ]

  •  Poor self-deport (3+ / 0-)
    Recommended by:
    blueoasis, hnichols, peptabysmal
    as McClatchy reported this week, "Not only might some states opt out of increasing the number of adults in the government health-insurance program for the poor as a result of the Supreme Court's ruling, but they also might cut people who now are enrolled."
    So they pressure the poor to self-deport to more compassionate states.  Gets ride of spongers and Democrats in one move,...and lots of them cullud folk.

    Is there no bottom to RepublicKlan depravity?

  •  I'm not following the reasoning (3+ / 0-)

    If states could throw folks off Medicaid rolls before the ACA decision, how did the decision open the door for it?

    I'm writing about the Medicaid expansion issue for Sunday, but I am not at all clear how you see the decision opening the door on something new in the existing Medicaid program.

  •  I'm always astounded about the child-free (0+ / 0-)

    Being cut out of everything, no matter how poor they are. It's set up to force as many poor people to reproduce as possible, and to keep the children rather than adopt them out (because the Medicaid and other services get cut right after birth if the mothers give up the children for adoption, with no follow up care).

    Guess they want more cannon fodder, more slave labor, and more prostitutes.

    Women create the entire labor force.

    by splashy on Thu Jul 05, 2012 at 12:56:50 PM PDT

  •  IIRC, the bill for those not covered by any of the (0+ / 0-)

    plans still has to be incurred by hospitals and those who work there, and it is collected back by increased charges to and therefore increased charges by the insurance companies. Which means that not taking Medicaid II will have the effect of increasing costs to all those who pay insurance premiums in a given state. Depending on the amount of those increased costs, it will be increasing bills for its employers and make the state doing this twiddle be less competitive for other businesses and other purposes. Losing the benefit to some degree of right to work laws and low low low minimum wages, all those things supposed to encourage businesses to come to said stupid states.

  •  I'm cynical enough to think that... (7+ / 0-)

    this will actually benefit the Republican campaigns with voters in those states.  The stupid-@ss voters will simply think "after Obamacare passed, I got dropped from Medicaid"   or "after Obamacare passed, insurance rates in my state went up."

    •  I saw it first hand at a town hall meeting... (6+ / 0-)

      ...on health care reform that was held by former congressman Mike McMahon here in Staten Island.

      One of the Tea Party speakers spoke about his child and how inadequate the medicaid coverage he got was and how he had to pay out of pocket for the care he needed.  He used this as evidence that government supported health care is wrong.

      And he was not the only tea partier to mention their medicare or medicaid.  It was surreal.

      The lady was enchanted and said they ought to see. So they charged her with subversion and made her watch TV -Spirogyra

      by Taget on Sat Jul 07, 2012 at 02:23:11 PM PDT

      [ Parent ]

      •  Every time I go to (4+ / 0-)

        one of our congressman's town halls, there's a line of people waiting to talk to him about getting SS disability.
        The town halls are filled with these farmers that get subsidized crop insurance, crop subsidies, low loan rates, all from the government, and yet they're "independent".

        “We are not a nation that says ‘don’t ask, don’t tell.’ We are a nation that says ‘out of many, we are one.’” -Barack Obama

        by skohayes on Sat Jul 07, 2012 at 03:06:08 PM PDT

        [ Parent ]

  •  TX Gov Perry talked about opting out (1+ / 0-)
    Recommended by:
    qofdisks

    But he found out most medicaid $$$ goes to nursing homes to care for grandma's... last i hear they just decided to slash the reimbursements enough to put 30%+ outta business

    Our president has his failings, but compared to Mitt Romney he is a paradigm of considered and compassionate thought.

    by OMwordTHRUdaFOG on Sat Jul 07, 2012 at 02:12:26 PM PDT

  •  Tell me again what it is our troops are (8+ / 0-)

    defending.  The American Way of Life?  And what has that become?  There's not much united in the United States any longer.  (Citizens United is just the name on the tombstone.)

    Romney went to France instead of serving in our military, got rich chop-shopping US businesses and eliminating US jobs, off-shored his money in the Cayman Islands, and now tells us to "Believe in America."

    by judyms9 on Sat Jul 07, 2012 at 02:15:22 PM PDT

    •  What they're mostly defending (1+ / 0-)
      Recommended by:
      qofdisks

      Have you seen the Pentagon budget lately?  Have you seen the expenditure our country lays out on our military efforts?  There are a great many people that are getting just crazy rich in the defense industry, my friend.  

      Of course, without that, we'd lose what...a couple million jobs plus or minus?  This is a double-edged sword, so to speak.  Reduce military spending and drastically increase unemployment and suffer huge losses in taxes and other revenue realized.  Continue military spending (and efforts both at home and overseas militarily) and all of those companies that employ all of those citizens keep their jobs not to mention the military infrastructure within just so many states that drastically help those states fiscally.

      We're winding down Iraq and we're seeing a huge increase in those troops coming home being homeless and unemployed and without any kind of health care.  Think about how an ever-increasing reduction in military spending will affect our country...our citizens.  

      It's a conundrum, no doubt.

      The truth is sometimes very inconvenient.

      by commonsensically on Sat Jul 07, 2012 at 02:35:27 PM PDT

      [ Parent ]

    •  Has anything changed since Katrina? (6+ / 0-)

      not that I'm aware of.

      This is a country that lets the poor drown. So letting them die from lack of medical care seems par for the course.

  •  This will take an enormous amount of money (0+ / 0-)
    The expansion of Medicaid to families earning 133 percent of the federal poverty level (FPL) and the availability of subsidies to those at four times the FPL will enable coverage for over 30 million more people nationwide. (Of these, the Urban Institute estimated that 8.1 million Americans would have their insurance paid for in full by the expansion of Medicaid. Another 10.9 million people would receive subsidies to buy private insurance in the new state exchanges, while only 7.3 million, 2 percent of the total U.S. population, would be required to purchase a health plan using their own resources alone.)
    I'm sure this won't be popular here, but let's say every state did "expand" Medicaid as is being presented.  Looking at the blockquoted statement above, this has to cost a huge amount of money to implement and get everyone with healthcare.  Every citizen in America should have access to healthcare if for no other reason than we are just that kind of country.  

    But, the overriding question just HAS to be: "where is that money going to come from?".  This isn't a one-time, big budget item...this is money that will have to be expended on an ongoing basis forever.  

    It just HAS to be the big question in all of this.  Anyone with any empathy in their heart doesn't want any American to suffer or even die because of no access to medical care.  No one (with exceptions, of course) wants kids in America to not have this kind of access.  

    How is this going to be funded?

    The truth is sometimes very inconvenient.

    by commonsensically on Sat Jul 07, 2012 at 02:15:33 PM PDT

    •  Replace the (5+ / 0-)

      entire health insurance industry with civil servants.

      Next question.

      •  How about (3+ / 0-)
        Recommended by:
        skyounkin, pronin2, nolagrl

        Medicare for all.

        Sheeesh.  This is so hard to get through people's heads (and, by "people", I mean republicans).

        They just can't see the forest for the trees.

        Damn.

        The truth is sometimes very inconvenient.

        by commonsensically on Sat Jul 07, 2012 at 02:28:10 PM PDT

        [ Parent ]

        •  Why is Medicare for all cheaper than (0+ / 0-)

          Medicaid for all-below-133%?  I'll answer my own question in part - Medicare requires co-pays, Medicaid largely doesn't.  But Medicaid is often a gap-filler for current Medicare recipients so that's not really a complete answer.

          "The first drawback of anger is that it destroys your inner peace; the second is that it distorts your view of reality. If you come to understand that anger is really unhelpful, you can begin to distance yourself from anger." - The Dalai Lama

          by auron renouille on Sat Jul 07, 2012 at 02:38:08 PM PDT

          [ Parent ]

    •  It's all been paid for... (7+ / 0-)

      and it was scored by the CBO. It's been available online for over 2 years now. www.whitehouse.gov

      "We love this goddman country and we're taking it back!" Saul Alinsky

      by mindara on Sat Jul 07, 2012 at 02:31:18 PM PDT

      [ Parent ]

      •  Hmmmm (0+ / 0-)

        Hasn't the CBO changed their projections on cost?  

        I'll have to look around and see what's up with that.  I'll also do more homework on it before I approach the issue again.

        Thanks.

        The truth is sometimes very inconvenient.

        by commonsensically on Sat Jul 07, 2012 at 02:39:23 PM PDT

        [ Parent ]

      •  More on Funding Issues (5+ / 0-)

        Mindara is right that the roughly $950 billion cost of the ACA over 10 years has been paid for.  The funding comes from about $525 billion in new tax revenue and another $500 billion in savings from the growth of Medicare.  (That's why the CBO repeatedly concluded the ACA REDUCES the national debt.)

        That said, when the federal govt's contribution for each state's Medicaid expansion drops to 90 percent, the states will have to come up with the difference.  So, it is true that a state like MS or AL might have to produce $2 billion over the following ten years; TX and CA would have to produce a lot more.  Still, this is a sweet deal for the states and one they have plenty of time to plan for.

        •  If this increases costs to the feds (0+ / 0-)

          doesn't this mean the Republicans could gut the ACA law in the Senate using reconciliation?

          Which is good news for John McCain.

          by AppleP on Sat Jul 07, 2012 at 03:00:52 PM PDT

          [ Parent ]

        •  How can there be savings (0+ / 0-)

          on the growth of Medicare?   As of Jan 1 2011, 10,000 baby boomers reach age 65 everyday for the next 19 years.

          •  Yes, but we won't all be signing up. (3+ / 0-)
            Recommended by:
            Mr Robert, Pescadero Bill, qofdisks

            When we don't get Social Security until 66 or 67, how are we supposed to PAY for Medicare? The bottom half of the boomers (remember, baby boomers range from birth in 1946 to 1964) had our eligibility changed. We don't get SS at 65. We have to wait until 66 (+ months) and 67.

            It's like saying OMG Social Security is going to go broke because X-number of boomers reach 65 each day! You have to remember that a great number of us aren't eligible for two more years AFTER we turn 65 and become eligible for Medicare.

            Since more and more of us are unemployed, just who do you think is going to be signing up to pay for something for which we have no funds?

            It's yet another black hole into which the most unfortunate will be thrown.

            "The difference between the right word and the almost-right word is like the difference between lightning and the lightning bug." -- Mark Twain

            by Brooke In Seattle on Sat Jul 07, 2012 at 03:37:20 PM PDT

            [ Parent ]

    •  Everyone already gets care (4+ / 0-)

      Poor folks wait until they are sufficiently ill that they can't put it off longer and go to emergency room, where their care is enormously expensive. Poor preventative and diagnostic care then leads to high cost responses to problems that might have been dealt with inexpensively if caught early.

      Currently that high cost care is either passed on to the government or to insured patients in the form of higher charges to cover the unreimbursed costs. The cost hot potato of trying not to pay and pass the costs along to someone else drives most of the high cost of administering insurance and all the insurance nightmares that led to the PPACA in the first place.

      The ACA tries to ensure that every American has access to regular checkups and preventative screenings because that saves money over the long haul. It also tries to tie a funding stream to every individual so that we don't have the kind of backdoor cost sharing which distorts costs and incentives.

      This is why the Republicans aren't actually gonna do any of this. They are turning down billions of dollars which would go to hospitals and physicians in the states, with hardly any state match. Aint gonna happen.

      e

      •  Yes (2+ / 0-)
        Recommended by:
        Eric Nelson, Calamity Jean

        And I hope that those with questions above read what you have said here.

        To support the latter part of your comment, I posted this the other day:

        In quiet rooms, even the reddest teabagger idiots will be pressured to take the money for the Medicare expansion.  Otherwise, the state govts will pay the costs themselves.

        Donald Berwick, former head of the Centers for Medicare and Medicaid Services, which administers the two programs, said few states were likely to take that risk.

        "Those people are still living in your state, They're still poor. They're going to come to your emergency room. They're going to be operated on, and they're going to have diseases that get worse, and you're going to have to pay for that. That will come from the state — free care pools and charity in the state," Berwick said in an interview on MSNBC-TV.

        "I think what's going to happen is the states are going to be under pressure from providers of care who say: 'Why are you leaving this money on the table? Let's join in with the federal dollars.'"

    •  Ok, here's some more reading for you... (2+ / 0-)
      Recommended by:
      indie17, Eric Nelson

      Every one of these links are worth reading, and each has other worthwhile links to explore:

      No, 'Obamacare' isn't the largest tax increase in the history of the word (in one chart).

      Of the fifteen most significant tax increases since 1950, the Affordable Care Act tax increase is the 10th largest and amounts to a tax increase of 0.49 percent of GDP. The ACA increase is considerably smaller than the Reagan tax increase of 1982, and comparable to the Bush I tax increase of 1992 and to the Clinton tax increase of 1993.

      Note that the tax increase is on several different sources; the only increase to personal income tax begins 2013 as an increase of less than one percent for individuals with income over $200k per year.  For covering 30 million uninsured people and all the other benefits of the ACA, that tax increase is a bargain.

      Here are some more:
      GOP Governers say Medicaid costs are already breaking states’ backs. Are they right?

      The Affordable Care Act's Giveaway to Stingy Red States

      Obamacare's Medicaid Expansion Already Covering a Half-Million Americans

      There... I decided to stop there. That ought to keep you busy for a bit.

      The sh*t those people [republicans] say just makes me weep for humanity! - Woody Harrelson

      by SoCalSal on Sat Jul 07, 2012 at 03:18:40 PM PDT

      [ Parent ]

    •  Moneygrubbing (2+ / 0-)
      Recommended by:
      Eric Nelson, Calamity Jean

      How about changing the discussion to:

      "Is this the very best we can to help people with the dollars we have, or how do we make it the best?"

      Money is a tool to aid human happiness.  Happiness of all has to take precedence, or all suffer.

      No one's suffering is acceptable.  Christian dogma claims all humanity is responsible because we let Jesus suffer.

      They are supposed to make themselves whole by alleviating the suffering of others.  Yeah, those 'Others', too.

      Everything else is window dressing.

      So, let's get American and take pride in how we treat each other.

    •  Long term, the expense will be folded into the (0+ / 0-)

      cost of running the country.  The longer it is implemented and fine tuned, the more it will invisibly be absorbed.
      Think of it like this.
      Say I get a paycheck.  I put 50% of my check into savings every payday via automatic electronic transfer.  I don't even "see" it, I don't even think about it.  Then, I actually live on the rest on a budget.
      No, I never buy a new car or take an expensive vacation but, I buy the necessities to live comfortably.  
      Over time, accommodation is made without sacrificing necessities. We will "feel" it at first then, wages will accommodate it or the government will have it hardwired automatically budgeted in.

  •  Only one question needs to be asked. (0+ / 0-)

    Does this help private insurers?
    It looks like anyone who earns at or below 133% of poverty and is not eligible for Medicaid will have to purchase a (private/exchange) plan, or pay the “tax” (i.e. the enforcement mechanism for the mandate).
    The answer to the question is yes. Less public-sector = more private-sector. That explains this ruling (i.e. follow the money). It also explains CU.

    •  I may be mistaken but (0+ / 0-)

      I believe that there are significant exemptions from the penalty:

      33 percent of the population under age 65 would be explicitly exempt from the individual responsibility requirement. These are people whose incomes fall below the tax filing threshold, those for whom the direct premium of the lowest cost available plan exceeds 8 percent of family income,3 and undocumented immigrants.
      http://www.urban.org/...
  •  We need to wise up. (9+ / 0-)

    Their goal is the raw pursuit of power. This is no longer a political party with a different viewpoint on how to do best by the nation. It is an international crime family. You can expect every state controlled by Republicans, at least 26 of them (the ones who brought the case to the Supreme Court) to sit on their hands. Their goal, as previously enunciated by McConnell, is to cause the President and Democrats to fail.

    This goal is purely destructive. They have no better idea. They merely wish to destroy the other party and they are willing to create human misery to do it.

    Their concept is simple: cause the Affordable Care Act to become unaffordable because the Federal Government will be obliged to pick up the costs, and by reducing the economies of scale in the market place that having nearly everyone insured would afford.

    The fewer insured, the better from their point of view.

    These people obey no law. They have outlawed abortion in Mississippi (the law has temporarily been halted by a court).  They merely wish power so that they can destroy government altogether except as a funnel for taxpayer funds to private corporations.

    •  We just have to make sure they don't succeed. (7+ / 0-)

      I don't know about the rest of you all, but I am sick of these mother f*ckers. The house they reside in is OUR House, I think it's high time we took it back.

      "We love this goddman country and we're taking it back!" Saul Alinsky

      by mindara on Sat Jul 07, 2012 at 02:43:13 PM PDT

      [ Parent ]

    •  It is more than just wanting to win (10+ / 0-)

      These folks want no safety net run by the Federal Government.  None.  Zip. They call it Socialist Oppression when we band together to stabilize the economy and help those in trouble. They never wanted Medicare and they never wanted Medicaid (just look back at the partisan votes in Congress) They will use the excuse of states rights to eliminate them if they can.  I know for certain that the GOP majority here in NH will vote to turn down Federal health funds because they have already voted to do so. Their excuse is that instead, every Medicare recipient will get a 5 K voucher to buy their own private insurance.  Can you imagine the policy that an elderly person could get for that amount?  It is easy to imagine as the NH high risk policy has a $10,000 annual deductible and costs over $6,000 a year.  Yet, older people in the state aren't up in arms about this.  They just don't understand what is about to happen to them if the GOP stays in power.

      •  When will it be time... (0+ / 0-)
        They never wanted Medicare and they never wanted Medicaid (just look back at the partisan votes in Congress) They will use the excuse of states rights to eliminate them if they can.  
        for this President to declare a National Emergency~?
    •  When the National Democratic (4+ / 0-)

      party comes out with a statement like yours and backs it up with a two hundred million dollar ad campaign showing examples then we may begin to turn it around.

      Until then they will continue to lie, cheat and steal to turn the country into Mississippi.

      Which is good news for John McCain.

      by AppleP on Sat Jul 07, 2012 at 03:03:55 PM PDT

      [ Parent ]

  •  Win the battle, lose the war? eom (1+ / 0-)
    Recommended by:
    sebastianguy99

    I know you believe you understood what you think I said, but I'm not sure you realize that what you heard is not what I meant. -- S.I. Hayakawa

    by tapu dali on Sat Jul 07, 2012 at 02:24:23 PM PDT

  •  For Heaven's sake, can't anybody on our team (6+ / 0-)

    play this game?  

    This is like watching the original Mets under Casey Stengel play baseball.  Why don't we just give up and let the GOP dictate who can vote, who gets social assistance, and which country we get to bomb next.  Surely there are smart people out there with progressive values who are waiting to be tapped to play a role in American politics on our side!  We have to keep fighting every fight over and over and over.  Meanwhile the world is burning up, and Mitch-freaking-McConnell wanders around saying the human race (aka the free enterprise system) can figure out how to deal with that little problem in a couple hundred years.

  •  Big Talk (10+ / 0-)

    I think, in the long run, this will be seen as just a lot of posturing and Big Talk.  Hospitals and doctors are going to want to be paid and will apply lots of pressure on the guvs.

  •  The Arizona issue is more nuanced... (0+ / 0-)

    The current Medicaid waiver was enacted with tobacco settlement money and is likely to expire before 2014; Arizona will benefit enormously from the Medicaid expansion if accepted, as the current plan appears to be to kill off the current Medicaid expansion; it is already not accepting new enrollees and current enrollees are kind of living in fear.

    "The first drawback of anger is that it destroys your inner peace; the second is that it distorts your view of reality. If you come to understand that anger is really unhelpful, you can begin to distance yourself from anger." - The Dalai Lama

    by auron renouille on Sat Jul 07, 2012 at 02:34:49 PM PDT

  •  This is an opportunity (4+ / 0-)
    Recommended by:
    Sherri in TX, Aquarius40, Matt Z, qofdisks

    When Republican governors drop Medicaid while Democratic governors embrace it, there will be a huge difference in results for people that will impact voting decisions down the road.

    Stop whinging. You got a gift. If you embrace it as such.

    http://www.danablankenhorn.com

    by Dana Blankenhorn on Sat Jul 07, 2012 at 02:36:28 PM PDT

  •  Barbaric. n/t (3+ / 0-)
    Recommended by:
    nolagrl, Brooke In Seattle, Matt Z

    The thing about democracy, beloveds, is that it is not neat, orderly, or quiet. It requires a certain relish for confusion. Molly Ivins

    by MufsMom on Sat Jul 07, 2012 at 02:43:43 PM PDT

  •  TYPICAL white collar bullshit. NO thought of what (1+ / 0-)
    Recommended by:
    qofdisks

    the point of health care is,

    and how to best get there ---

    just rules and rules and rules for fucking bureaucrats and fucking lawyers and fucking consultants and sundry other fucking pinheads -

    know why it is soooooooooooo EASY for the fascists to tear apart community programs ?? 'cuz of bullshit like this.

    Your voter registration / driver's license should be your health card ... period, over, end of story --

    more fucking programs with more rules and more loopholes and more plundering management accomplishes WHAT?

    rmm.

    Yond Cassius has a lean and hungry look; He thinks too much: such men are dangerous

    by seabos84 on Sat Jul 07, 2012 at 02:49:55 PM PDT

  •  We will have to do two things (3+ / 0-)

    1) This is an issue progressive can rally the poor around in red states.

    2) One thing we can learn from the right is to be relentless. Once we get both houses back we should push. Where is the line on coercion? Not increasing any other aid? Less increase in aid? Withdrawing only 49% of aid so they still retain the majority? Allow the public option first in states that don't expand eligibility?  Play hard ball. We can't win most of these states anyways, so politically there is little fallout from helping the poor there.  But in the long term helping these the poor in these states can be our FDR moment.

     

    -1.63/ -1.49 "Speaking truth to power" (with snark of course)!

    by dopper0189 on Sat Jul 07, 2012 at 02:50:39 PM PDT

  •  This will end badly (2+ / 0-)
    Recommended by:
    Eric Nelson, qofdisks

    for Republicans. Deliberately preventing their residents from receiving benefits that people in other states enjoy will shine a bright light on their callousness.

    I think it's another manifestation of the false bravado that today's right wing nutbars seems addicted to. When push comes to shove, I believe most of them will take the money, all the while decrying creeping socialism.

    "A lie is not the other side of a story; it's just a lie."

    by happy camper on Sat Jul 07, 2012 at 02:53:19 PM PDT

  •  Why do we put up with state sovereignty? /nt (0+ / 0-)
  •  And Medicare for all would solve all this, yes? nt (3+ / 0-)
  •  Wait a sec. (0+ / 0-)
    In the wake of the Supreme Court decision in NFIB v. Sebelius, the greatest threat to enabling health insurance for 30 million uninsured Americans . . .
    I thought there were 50+ million odd without Healthcare Denial Industry coverage?

    Did 20 million Americans just get disappeared on the politicking frontpage of dkos?

    This is an odd sort of solidarity to expect anyone to find compelling.

    Please don't feed the security state.

    •  ACA won't cover everyone that (2+ / 0-)
      Recommended by:
      Brooke In Seattle, Eric Nelson

      needs insurance. If I remember, the figure of 47 million uninsured adults and children was used back during the debate.
      The ACA will be able to cover 32 million through expansion of Medicaid, others will be covered by being able to stay on their parents insurance, some will be covered by the high risk pools, etc.

      “We are not a nation that says ‘don’t ask, don’t tell.’ We are a nation that says ‘out of many, we are one.’” -Barack Obama

      by skohayes on Sat Jul 07, 2012 at 03:23:33 PM PDT

      [ Parent ]

    •  Let me get this straight. (0+ / 0-)

      I'm supposed to find 30 million freeloaders compelling, but 20 million skating deadbeats just don't register at all?

      Wait a sec.  

      Is this like a kossack Jedi Mind Trick?

      You know, in which Big-Boy Pants(tm) Dem stoogery and wonk-shaping are made to seem compelling or perhaps  even progressive (to those weak of mind)?

      OOooooO.

      Please don't feed the security state.

  •  As my doctor said yesterday (4+ / 0-)

    It all comes down to racism.

    The Muslim said "I wished I had met Christ before I met the Christians" - Rev. Marvin Winins

    by captainlaser on Sat Jul 07, 2012 at 03:24:27 PM PDT

  •  So, because of an overlooked funding glitch, (2+ / 0-)
    Recommended by:
    Palafox, qofdisks

    some Americans in states run by the plantation mentality will be treated less equitably than fellow citizens in more progressively-minded states.  This is inherently unequal and untenable.  Are we really one nation or are we a patchwork confederation?  And which do we really, truly want to be?  That's the existential question I see coming out of this, and it makes a mockery out of the old sentiment E pluribus unum.

    More practically, a couple of things are likely in this situation:  the working poor with chronically ill family members who might have family willing to pool some money for relocation might be able to migrate to states like Maryland, Massachusetts, Oregon, etc. in order to get services.  Others will suffer and see their quality of life -- probably even their lifespans -- diminish even more quickly in states like Georgia, Alabama, Louisiana, Texas, etc.  Meanwhile, the glaring solution, Medicare for all, will continue to be more fervently wished for by the uninsured and the self-payers.

    Can we get to single payer/Medicare for all?  Maybe, eventually.  If -- and I really hate to think this way -- if enough people die from unequal coverage and enough survivors (the widowed, the orphaned) raise holy hell.  They say it is always darkest before the dawn.  Well, it doesn't get much darker than the grave.

    So, what are we going to do about it?

    "Fighting Fascism is Always Cool." -- Amsterdam Weekly, v3, n18 (-8.50, -7.23)

    by Noor B on Sat Jul 07, 2012 at 04:13:13 PM PDT

  •  Harsh times ahead for some Red State voters.... (4+ / 0-)
    Recommended by:
    Matt Z, indie17, Calamity Jean, qofdisks

    For every Red State billionaire and Tea-vangelist who rejoices at the shredding the safety net that they don't need - we'll see tens of thousands of everyday folks struggling to survive without basic medical care and health services.

    Maybe Dick Armey will provide them with festively arrayed Americans for Prosperity buses again. This time to drive off a cliff.

  •  Who'll be the first in line to deny Medicaid (0+ / 0-)

    to current enrollees? Sounds like a winning platform for the competing party if I ever heard one.

    GOP = Greedy One Percent

    by Palafox on Sat Jul 07, 2012 at 05:19:33 PM PDT

  •  First thing that comes to my mind (1+ / 0-)
    Recommended by:
    Calamity Jean

    Republicans are doing a form of "Cleaning House" in their states.... Get rid of the poor, you know, like how Katrina cleaned out New Orleans.

    Sick bastards if that is what they are doing.  How can you not have a heart for people, how?

    -6.13 -4.4 Where are you? Take the Test!!!

    by MarciaJ720 on Sat Jul 07, 2012 at 07:36:08 PM PDT

  •  This is what you get when you pass a conservative (0+ / 0-)

    law written primarily by insurers...

    It got to the Supreme Court, where apparent horse trading occurred.

    So more people than expected will pay the tax (insurers are not going to give out deals), get mad at Democrats, and continue giving Blue Dogs and the RW oxygen.  

    The good news, in Blue States a lot of people will be helped.

    The question is will the laws get better or worse when the issues are addressed.  My suspicion is worse, because of the deficit.

    So frustrating...

    "But once John Boehner is sworn in as Speaker, then he’s going to have responsibilities to govern. You can’t just stand on the sidelines and be a bomb thrower." - President Obama, 12-07-2010

    by justmy2 on Sun Jul 08, 2012 at 07:37:46 AM PDT

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