It seems unbelievable- but it’s been just over a year since the Supreme Court solidified the ACA as the law of the land. In that time, rather than becoming a settled matter, with time and effort moving full force on to implementation, the political turmoil has continued, particularly at the state level. When the Court decision devolved the decision to join the Medicaid expansion to the states- it became at opt-in system. The expansion will cover people up to 138% of the federal poverty line, somewhere around $32,000 for a family of four, with the federal government picking up the tab completely for the first three years, and 90% thereafter.
If all the states chose to join, this would provide access to quality care and a desperately needed sense of security to 15 million people nationwide, bring stability to the hospital systems that have until now had to shoulder the burden of providing “uncompensated care,” and further bring the American health care system in line with the goal of universal health care coverage for our people. But so far, as Medicaid expansion is debated in the political telenovela that local and state politics can be- only 23 states and the District of Columbia have moved forward with the program. Among these states are 6 Republican led, including Arizona, which was the last state to ratify the original Medicaid program in 1982, a full 27 years after it was signed into law by LBJ in 1965.
This leaves which 21 states have rejected what would amount to free money on the table to help our citizens who need it most, and 6 states remain undecided. This could leave as many as 9.7 million people without access to state-sponsored medical insurance, nearly ⅔ of those eligible to receive coverage through this piece of the ACA. Because of how the law was crafted, presuming that everyone up to 138% of the FPL would be plugged into the system through Medicaid, subsidies on the state and federal exchanges were designed for those between 138-400%, leaving a glaring gap in options for those falling below those mentioned income levels. What happens to them- could quite possibly be remaining without affordable care while those in other parts of the country benefit from coverage paid for with federal taxes. My own state is currently playing out this drama, in a truly Shakespearean fashion.
For Pennsylvania, Medicaid expansion would mean 700,000 low-income residents would receive access to affordable, quality health care. Estimates of upwards of 40,000 jobs would be created, while receiving nearly 4 billion dollars in federal funding in the first 3 years. Independent analysis in the state has indicated that the expansion would be a net surplus for the state coffers, as uncompensated care costs the state nearly a billion dollars a year. The state governor has been reticent to accept expansion, citing concern over even the small increase in state outlays for coverage. However, the door has never been closed to some sort of flexible plan, perhaps along the lines of the Arkansas hybrid plan. After a number of concessions over the past week, he appeared willing to accept a compromise position if the plans under expansion included a number of small cost-sharing requirements. A bipartisan group in the state Senate had carefully crafted a compromise, including language acceptable both across the aisle and to the governor. It was written into the annual budget. But the more conservative House stripped the language from the bill, with the Speaker tenuously citing the belief that it should be worked out between the governor and federal officials, not the legislature. Now the budget bill will go back to the Senate in the next few days- where how to address the removed language will surely be vigorously debated.
This saga is ongoing, and not just in PA. When the last chapter will be written, we cannot be sure. Unlike the health exchanges, there is no deadline for joining the Medicaid expansion. Each quarter, each election, represents a new opportunity to rectify decisions which left our fellow citizens without something the vast majority of us take for granted. This may very well make Medicaid expansion a marathon, or maybe even one of those ultra races where people run hundreds of miles through the desert barefoot. But it means there is always room to rewrite the ending. Remember- it took Medicaid proper 27 years. Surely we can do better.