Many Governors Are Still Unsure About Medicaid Expansion

[steve2470]

http://www.nytimes.com/2012/07/15/us/governors-face-hard-choices-over-medicaid-expansion.html?pagewanted=all

WILLIAMSBURG, Va. — How well the new health care law succeeds in covering millions of the poorest Americans will depend largely on undecided governors of both parties, who gathered here this weekend and spoke of the challenges of weighing the law’s costs and benefits in a highly charged political atmosphere and a time of fiscal uncertainty.

The Supreme Court’s ruling last month that the states should have the choice of whether to expand their Medicaid programs has set the stage for a frenzied year and a half in which governors will have to analyze their options, devise plans, negotiate with the federal government and successfully navigate the thorny statehouse politics that often accompany any big change. Much of the law is set to take effect in 2014, when many governors will be facing re-election.

The initial reaction to the court’s ruling split along party lines. More than half a dozen Republican governors — including those of Texas and Florida, which have the nation’s largest populations of poor uninsured residents — said they would not expand their programs because Medicaid already eats up an unsustainable share of their budgets. A slightly bigger number of Democratic governors said they would move swiftly to expand coverage in their states, with the federal government pledging to pick up all the costs at first and 90 percent of them after 2020.

But as they gathered here this weekend at a meeting of the National Governors Association, most governors in both parties said that faced with a choice they did not expect to have, they needed to study how to proceed with this significant change in federal-state relations. Not all Democrats were leaping at the chance to expand their programs, and not all Republicans were ruling it out.

*end of excerpt*

Unsure ?? That's a nice way of saying " We're Republican governors and we want to sabotage the ACA".

[Igel]

1. Not necessarily.

There are a lot of assumptions, some patently false, in the media.

Like "if you're covered by insurance you won't go to the ER except for real emergencies." It's false, but we like to think it's true. It's certainly true for us, so it must be true for everybody. Eh.

But governors have to sort out the budget and public health implications. They're going to be at odds. It's a convenient fiction that all the assumed public health benefits will automatically lead to better budget outcomes. It's like assuming tax cuts always or even usually pay for themselves. There's theory, then there's actual results.

If Medicaid's expanded from 100% to 133% of the poverty level, and the Federal government has said it'll fully pay for the expansion for the first 3 years, you have to think: "What about the shortfall in Medicaid in my state so that people below 100% of the poverty line aren't fully covered? Will my state have to pay for them? How much will it cost?" You also have to think, "The Congress said it'll fully pay for coverage for the first three years, but they make some assumptions as to what the costs will be. Will the 2014 Congress actually be bound by a pledge made by the 2009 Congress and the president--not Congress--in 2012? And what will be the amount they pay in years 4 and 5 and beyond--will we be on the hook for 10% of the cost? More?"

If the budget numbers don't come out favorably, then they have to consider the likelihood of a tax or fee increase, and who would pay for Medicaid. What would be the economic implications? Political implications? What if the tax increases don't pass, what would they cut? What would happen if they had to take away Medicaid? After all, people feel much more strongly about having something taken away then never receiving it.

All those governors who have said "yes" have Medicaid currently funded at 95% or more of those below poverty. They'd have the least downside, the smallest immediate budget increases. All those who have said "no" have mediocre Medicaid coverage at present, and they'd have to have a hefty budget increase to come up to 100%.