In the closing days of state legislative sessions, lawmakers in more than a dozen states, including Maine, are struggling with whether or not to expand Medicaid under the federal health-care law, with many of them leaning against participating in a program that is key to President Barack Obama’s aim of extending coverage to 30 million uninsured Americans.
Twenty states and the District of Columbia have signed on to the expansion, and 14 are planning to decline. But 16 remain in limbo as lawmakers clash in the final days and weeks of the legislative calendar, when many must come to a decision in time for the provision to kick in next year.
The uncertainty comes at a moment of intense scrutiny of the way the administration has handled the rollout of the health-care law, with states at vastly different stages of implementation and the public confused about how the law will work. Obama offered reassurances this week, saying that “. . . what we’re doing is making sure that every single day we are constantly trying to hit our marks so that it will be in place.”
The three-year-old health-care law faces perhaps its greatest challenge this fall: enrolling millions of Americans in health insurance beginning Oct. 1.
Much has been left up to the states, which have taken up the law with varying levels of enthusiasm. More than half have decided not to set up the online marketplaces meant to help people find insurance and financial assistance, leaving the enormous task to the federal government.
The debate over Medicaid, the government health insurance program for the poor, has created some unusual battle lines. In Florida, Ohio, Arizona and Michigan, GOP governors wary of turning down billions of federal dollars have met with stalwart opposition from fellow Republicans in the legislature. The most closely watched of those states is Florida, where nearly 4 million people lack health insurance.
With the Florida legislative session slated to end Friday, prospects for the Medicaid expansion appear dim. But in a victory for the Obama administration Thursday, West Virginia Gov. Earl Ray Tomblin, a Democrat, announced his state would participate, a decision that is expected to make an additional 91,500 people eligible for Medicaid there.
In many states, health-care advocates have allied with business groups and hospitals to endorse expansion, which would be paid for in large part with federal dollars.
But they have been stymied by conservative groups and the tea party, which are using the Medicaid fight to make a last stand against a health-care law they have battled for more than three years.
“We have clear ability to affect these primary elections, and we promised these legislators that if they voted to accept money from the federal government takeover of health care in our state, that we would do all we could to replace them,” said Ted Stevenot, president of the Ohio Liberty Coalition.
Stevenot’s group went door to door, collecting Republican signatures in individual legislative districts to prove to lawmakers that their re-election efforts would be thwarted if they voted for the expansion. Their efforts appear to be paying off: The legislature rejected Republican Gov. John Kasich’s budget line item that would have allowed Ohio to accept the money.
But there is passion on the other side as well. Hospitals have been among the most vocal supporters of expansion because the health-care law will reduce the payments they receive to treat uninsured patients because of the expectation that most of those patients would have health-care coverage. Many now fear financial ruin without the Medicaid expansion.
Business groups say the huge influx of federal money would be a financial windfall. And health-care advocates point out that, in states that choose not to expand, the people left out will likely be fast food employees, grocery store cashiers, construction workers and other very-low-wage earners — millions of people who were supposed to be some of the prime beneficiaries of reform.
Because of a quirk of the law, they would neither be eligible for Medicaid nor qualify for federal subsidies to buy private insurance.
“If we don’t expand, we will cement our position as last on every health indicator,” said Roy Mitchell, executive director of the Mississippi Health Advocacy Program, who said 300,000 low-income people in the state would get coverage under the proposal. “Mississippi may not see the vision of health-care reform realized.”
Mississippi’s legislature was so divided on the issue that it closed out its session without even reauthorizing Medicaid at its current levels. Without a special session, the state will discontinue its Medicaid program July 1.
Still, experts say the fight is not over. Some states that are leaning against expansion are holding special sessions to consider their options. Others are considering a compromise measure that would allow them to use the federal dollars to buy people private insurance, an idea pioneered by Arkansas.
The issue remains open virtually everywhere, partly because there is no firm deadline to opt in or out, but also because of the huge sums of money at stake. The Obama administration has devoted half a trillion dollars over 10 years to fund the expansion, and many states have commissioned studies that show the money would be a boon to the local economy.
“This year I have been very cautious to say of any state, this is off the table,” said Nicole Kaeding, state policy manager for Americans for Prosperity, a conservative political advocacy group that has been lobbying states to reject expansion. “It’s always tempting to look at the promises of federal funding. These are some pretty big incentives.”
Medicaid is funded jointly by the federal government and the states. In most states, it is available only to children, pregnant women and extremely impoverished adults, but the law would allow them to include anyone making up to 138 percent of the poverty level, or $26,951 for a family of three in 2013 dollars.
The Obama administration had intended for the expansion to be mandatory. But the Supreme Court ruled last year that states could opt out, leading many Republican governors to do just that. The governors, including Texas Gov. Rick Perry and Louisiana Gov. Bobby Jindal, have opposed the expansion as an outgrowth of their objections to the law as a whole. They are against the idea of expanding a government entitlement program that they feel is ineffective, encourages dependency and contributes to the national debt.
And even though the federal government has offered to pay the full cost of the new enrollees for three years and the bulk of the cost thereafter, many Republicans argue there is no guarantee the government will fulfill its promise. They fear states could get stuck with the enormous bill — or face the politically unpopular possibility of kicking people off the rolls.