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The refusal of Republican-led states to accept the Affordable Care Act's expansion of Medicaid will rank among the greatest self-inflicted wounds in the recent history of American public policy. But in the red states where the GOP calls the shots, that act of pure political spite will produce not one crisis but three.

For starters, millions of their residents will needlessly remain uninsured thanks to the "coverage gap" produced by the denial of Medicaid coverage to those earning less than 138 percent of the federal poverty level. Adding insult to injury, as the Commonwealth Fund documented this week, coffers in Texas, Georgia, and more than 20 other states will lose out on billions of dollars of funding from Washington, D.C. even as their residents receive no benefits for the Medicaid tax revenues they supply. Making matters worse, red state hospitals will face a severe cash crunch and even closure unless their Republican leaders come up with the money to pay for the uncompensated care of those who could have been insured by Uncle Sam for free.

As McClatchy explained in August, Republicans have left 5.5 million people "in those 21 states to fend for themselves in the 'coverage gap,' a bureaucratic twilight zone where people with poverty-level incomes don't qualify for Medicaid and can't get tax credits to help buy coverage on the new insurance marketplaces."

Here's why. Roughly 260 million Americans (roughly 85 percent) already have health insurance provided by their employers, the government, or through individual policies they purchased. In places like Oregon, Colorado, New York, California, and other, mostly Democratic states, governors and state legislators accepted the expansion of Medicaid to provide free health insurance for those earning up to 138 percent of the federal poverty (FPL). For those earning between 138 and 400 percent of the FPL, the Affordable Care Act's subsidies will help them purchase insurance in the private market. But in the states where Republicans said "no" to the expansion of Medicaid, the picture is much different. As the AP described the gaping hole in July:

Nearly 2 in 3 uninsured people who would qualify for health coverage under an expansion of Medicaid live in states which won't broaden the program or have not yet decided on expansion.
More on those who don't qualify for Medicaid below the fold.

The resulting Republican body count is shocking. Thanks to the GOP's rejection of Medicaid expansion, 1.3 million people in Texas, 1 million in Florida, 534,000 in Georgia, and 267,000 in Missouri will be ensnared in the coverage gap.

Those millions of Americans are not alone. As Bloomberg and CNN recently documented, many of the hospitals, clinics, and emergency centers that serve them will be caught in the Republican health care coverage gap, too.

As the New York Times reported, Memorial Hospital in Savannah, Georgia, "is now facing the loss of nearly half of its roughly $100 million in annual subsidies known as disproportionate share hospital payments." The Times explained how the Republican temper tantrum after the Supreme Court made Medicaid expansion optional for the states is putting red state hospitals at risk:

Now, in a perverse twist, many of the poor people who rely on safety-net hospitals like Memorial will be doubly unlucky. A government subsidy, little known outside health policy circles but critical to the hospitals' survival, is being sharply reduced under the new health law.

The subsidy, which for years has helped defray the cost of uncompensated and undercompensated care, was cut substantially on the assumption that the hospitals would replace much of the lost income with payments for patients newly covered by Medicaid or private insurance. But now the hospitals in states like Georgia will get neither the new Medicaid patients nor most of the old subsidies, which many say are crucial to the mission of care for the poor.

Savannah Memorial has plenty of company in Georgia. Republican Governor Nathan Deal said no to $33 billion in new federal Medicaid funding over the next decade. But as the federal government significantly reduces funding on Disproportionate Share Hospital (DSH) payments for the care of the uninsured, states like Georgia which turned down Obamacare's Medicaid dollars will be on the hook to make up the difference. For Grady Memorial Hospital, the largest in the metro Atlanta area, what could have been an annual boon of $60 million and coverage for 27,000 uninsured patients instead will be a $45 million loss. Georgia taxpayers will have to pay more even as hospitals likely cut services. Meanwhile, three cash-strapped rural hospitals have already closed their doors. Another 15 may follow suit in 2014. All because a Republican Governor said "no" to free money from Washington, DC.

And the funding is virtually free to the states. The federal government will pay for 100 percent of the cost of the Medicaid expansion until 2017 and 90 percent after that. The loss to rejectionist red state coffers, the Commonwealth Fund found, is staggering. As USA Today summed it up:

By 2022, Texas could lose $9.2 billion by not expanding Medicaid as allowed under the Affordable Care Act, while Florida could lose $5 billion over that period, the study conducted by The Commonwealth Fund shows. ... Also during that period, the study showed, Georgia could lose $2.9 billion, while Virginia could lose $2.8 billion.

"There are no states where the taxpayers would actually gain by not expanding Medicaid," said Sherry Glied, lead author on the study. "Nobody wins."

But the billions the "opt-out" states will have to come up with in future years will be more than offset by their extra costs to compensate hospitals and other providers for the care of the uninsured. As Ezra Klein and Evan Soltas summed up an analysis by the RAND Corporation of 14 Medicaid rejecting states earlier this year:
It finds that the result will be they get $8.4 billion less in federal funding, have to spend an extra $1 billion in uncompensated care, and end up with about 3.6 million fewer insured residents.

So then, the math works out like this: States rejecting the expansion will spend much more, get much, much less, and leave millions of their residents uninsured. That's a lot of self-inflicted pain to make a political point.

Which is just one of the reasons why an increasing number of red state governors are accepting the dollars from DC. GOP governors in Michigan, Pennsylvania, and Ohio ran the numbers. In Ohio, Governor John Kasich's decision to take Washington's money will actually produce a $400 million surplus for the Buckeye State (one which Republican legislators want to give away in the form of more tax cuts). The simple math and simpler consideration in insuring millions of indigent patients as the DSH funding is reduced over time is precisely why hospital associations in Texas, Kentucky, Georgia, Mississippi, North Carolina, and every other state pleaded with Republican governors and legislatures to take Obamacare's money for Medicaid expansion. In October, the Fitch ratings agency released a special report titled, "Adverse Expansion: Hospitals, States and Medicaid," which warned that:
"Hospitals operating in states not expanding Medicaid, which usually have higher uninsured and poverty rates, will have to absorb the full impact of the ACA reimbursement cuts without the full benefit of increased insured volumes," said Adam Kates, Director in Fitch's Public Finance group. Texas, Florida, Georgia, Louisiana, Mississippi, and South Carolina are not expanding Medicaid and have among the highest uninsured and poverty rates, and some of the most stringent Medicaid eligibility requirements. Fitch believes hospitals in these states, particularly those with weak payer mixes, will be particularly vulnerable.
It's no wonder Arizona Governor Jan Brewer, certainly no friend of Barack Obama, explained her decision to extend Medicaid coverage to 300,000 more people in her state this way:
"It's pro-life, it's saving lives, it is creating jobs, it is saving hospitals."
Those are three pretty good arguments for avoiding the triple whammy so many Republican states are bringing on themselves.
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