GOP Governors Choose To Reject Increased Medicaid Coverage Funding

The Hill: 7 GOP Governors Reject Additional Medicaid Funding. A July 3 article in The Hill reported that “at least 15 governors have indicated they will not participate in the expansion of Medicaid under the healthcare law” including rejections from "[s]even states with Republican governors." From The Hill:

At least 15 governors have indicated they will not participate in the expansion of Medicaid under the healthcare law, striking a blow to President Obama's promise of broader insurance coverage.  

Before Thursday's Supreme Court ruling, states had the option of either increasing their Medicaid rolls or being penalized by the federal government. The high court struck down that offer as unconstitutional.

[...]

Seven states with Republican governors have given a flat “no” to the Medicaid expansion since the Supreme Court ruling, according to reports and press statements. [The Hill, 7/3/12]

Right-Wing Media Praise Medicaid Decision That Will Hurt Millions Of Struggling Americans

Palin: “I Would Like To See Governors Be Tough And Opt Out” Of Medicaid Expansion. During a June 2 appearance on Fox News' On the Record with Greta Van Susteren, Fox News contributor Sarah Palin claimed that she wanted to see GOP governors exercise their “10^th amendment rights” and opt out of Medicaid expansion. From the broadcast:

GRETA VAN SUSTEREN (host): Well, it'll be interesting to see what happens, especially -- I mean, the states have a decision to make right now with the Medicaid expansion, and they need to decide whether they're going to opt in or opt out. Under this decision, they have a chance to opt out, and that's a very sort of pricey matter for the states.

On the other hand, they're going to have a lot of people who don't have coverage, at least the ones with the large populations that are under certain income level. What -- what do you -- how do you foresee that whole Medicaid expansion thing unfolding?

PALIN: Many, many states are not going to be able to afford expansion of Medicaid and these exchanges that are going to try to be forced down states' throats through “ObamaCare.” I would like to see governors be tough and opt out of this and exert our 10th Amendment rights and tell President Obama, who does not understand the Constitution -- he even being a constitutional lecturer and supposed scholar in our Constitution, not understanding and probably never reading or absorbing the 10th Amendment to understand that states have rights.

We are sovereign states that can make up our own minds about our budgets and how to prioritize the dollars that we have and the dollars that are shared by the federal government to the states. I'd like to see constitutionally conservative governors opt out of have Obama is going to try to do to the people of America through mandates on top of what the states already have to provide. [Fox News, On the Record with Greta Van Susteren, 7/2/12]

Fox's Kilmeade Promotes Florida Governor's Decision To “Not Tak[e] Any More Money” For Medicaid Expansion. During the July 2 edition of Fox News' Fox and Friends, co-host Brian Kilmeade promoted Florida Gov. Rick Scott's decision to reject federal funding for the Affordable Care Act's Medicaid expansion, claiming “For the first few years, the federal government will be handing the stats some money” but that "the money will go away and that has not eluded Governor Rick Scott. From Fox & Friends:

KILMEADE: That has a lot of governors saying to themselves, do we really want to do this? Also, part of making ends meet and giving everybody 100 percent medical care is having the states expand Medicaid to include more people. So for the first few years, the federal government is going to be handing the states some money and saying, “Pay out all these people,” and then that money is going to go away. And that has not eluded Governor Rick Scott, it has not eluded Governor Scott Walker or Governor Bobby Jindal, who all have said, “We're going to listen to the court. We are not going to expand Medicaid because in that decision, when everybody was focused on Obamacare live or die, it also said you cannot punish states for not taking extra Medicaid money.” So as of now, Governor Rick Scott among -- maybe even Governor Rick Perry will say we're not taking more money. 

GRETCHEN CARLSON (co-host): Because, I think, the Medicaid expenses for Governor Rick Scott in Florida have gone up 3 1/2 times what they were in just the last couple of years. So if you look down the pike into the future, you can't pay for it if you're not going to get the federal funding past a couple of years. [Fox News, Fox & Friends, 7/2/12]

Breitbart.com: More Governors Opting Out Of Medicaid Expansion Would Be “A Boon To Freedom.” In a July 2 Big Government post, Breitbart.com blogger AWR Hawkins, claimed that Scott's decision to opt out of Medicaid expansion was “a boon to freedom”:

It would be a boon to freedom if Republican governors like Scott, and others who say they'll join him, are able to withstand the pressure to go along with the federal government on Obamcare, thus contributing significantly to the efforts to repeal this monstrosity. [Breitbart.com, 7/2/12]

Hot Air Blogger: Governors “Being Frugal” About Expanding Medicaid “Warm[s] My Heart.” A July 2 post on the conservative blog Hot Air, praised the decision to forgo additional Medicaid funding as “being frugal.” From the post:

Not only are the governors being frugal -- no point wasting money getting started on this thing while it's still feasibly going to be repealed or altered -- but I also respect the tenacity. The outspoken unwillingness to just roll over and die never fails to warm my heart. [HotAir, 7/2/12]

CBO Estimates Medicaid Expansion Measure Will Insure Millions Of Low-Income Americans

CBO: Medicaid And CHIP Expansion Will Insure Up To 17 Million Americans. In a March 2012 update of its estimates, the Congressional Budget Office (CBO) predicted that “from 2016 on...16 million to 17 million people” will be enrolled under the expansion of Medicaid and the Children's Health Insurance Program (CHIP). [CBO, March 2012]

Opting Out Of Medicaid Expansion Would Leave Many Vulnerable People And Families Uninsured

Sargent: “Millions Could Go Uninsured” If “These GOP Governors Make Good On Their Threat.” In a July 3 post on the Washington Post's  Plum Line, Greg Sargent explained that “nearly one and a half million people” could lose access to health care if GOP governors follow through on their threat to not accept additional Medicare funding. From the post:

Iowa governor Terry Branstad has now become the fifth GOP governor to vow that his state will not opt in to the Medicaid expansion in the wake of the Supreme Court ruling. He joins the ranks of Louisiana's Bobby Jindal, Florida's Rick Scott, South Carolina's Nikki Haley, and Wisconsin's Scott Walker.

It's worth keeping a running tally of how many people could go without insurance that would otherwise be covered under Obamacare if these GOP governors make good on their threat.

The latest rough total: Nearly one and a half million people.

As Sarah Kliff noted the other day, the Kaiser foundation has done a state by state analysis meant to gauge how many people would gain coverage under the Medicaid expansion that didn't have coverage before. Keeping in mind that this study was performed in 2010, and that these are estimates, here's how many people we're talking about in each state:

* Iowa: 74,498

* Louisiana: 277,746

* Florida: 683,477

* South Carolina: 247,478

* Wisconsin: 127,862

The approximate total now, according to Kaiser's numbers: 1,411,061.

Now, in fairness, as Kliff notes, some of these people might be able to get insurance via other provisions in Obamacare, such as subsidies for buying insurance on the exchanges. On the other hand, Kaiser estimates that if states practiced aggressive outreach on the Medicaid expansion, even larger numbers of people than the above tallies suggest could get coverage under the provision. But again, Kaiser's numbers are estimates. [The Washington Post, 7/3/12]

CNNMoney: Opting Out Of Medicaid Expansion Could “Mean Trouble For Many Poor Adults.” A June 29 CNNMoney article explained that if a state chooses to opt out, struggling Americans could end up not having health insurance because they don't qualify for Medicaid under current eligibility guidelines. From the article:

The states can opt out of the Medicaid expansion program, since the court said the federal government can't penalize them by withholding all Medicaid funding. Instead, these states wouldn't get the additional Medicaid money to cover newly eligible enrollees. 

And that could mean trouble for many poor adults who are not eligible for Medicaid under the current system but would have qualified under the expansion. [CNNMoney, 6/29/12]

NY Times: Opting Out Of Medicaid Expansion Would Leave “Parents And Other Adults Working For Low Wages...Out In The Cold.” A July 2 New York Times article quoted a health policy analyst at the Center for Budget Priorities (CBPP):

Millions of poor people could still be left without medical insurance under the national health care law if states take an option granted by the Supreme Court and decide not to expand their Medicaid programs, state officials and health policy experts said Friday.

[...] 

“Because the expansion is such a good deal for states, they should move forward and cover low-income adults in their states,” said Judith Solomon, a health policy analyst at the Center on Budget and Policy Priorities, a liberal-leaning research and advocacy group. “But what happens in states that do not go ahead and provide coverage? The poorest adults -- primarily parents and other adults working for low wages -- will be left out in the cold.” [The New York Times, 7/2/12]

CBSNews.com: Opting Out Could Leave Millions Of Americans Uninsured. In a July 2 article, CBSNews noted that in Florida, opting out of additional Medicaid funding would leave “a significant portion of their citizens without health care.” From CBSNews.com:

Some health care experts said it was unthinkable that state leaders would really opt out, since the vast majority of the cost is covered by the federal government -- taxes their citizens will pay, regardless of whether the state opts in or out. For the first two years, the federal government pays for 100 percent of the expansion. Starting in 2017, the states start chipping in, but they will never contribute more than 10 percent of the cost.

“A governor would be walking away from millions, in some cases billions of federal dollars,” Tim Jost, a consumer advocate and professor of health law at Washington and Lee University, told CBSNews.com.

Furthermore, they'd be leaving a significant portion of their citizens without health care. Florida, according to the nonpartisan Kaiser Family Foundation, has the second-highest rate of uninsured Americans at 21 percent. The expansion of Medicaid in the state would have covered 951,622 people according to Kaiser. [CBSnews.com, 7/2/12]

Additionally, States “Can't Afford Not To” Participate In The Medicaid Expansion

Ezra Klein: States “Can't Afford Not To” Participate In Medicaid Expansion. In a July 2 Washington Post column, Wonkblog's Ezra Klein pointed out that states currently pledging to not participate in the expansion will most likely do so anyway because “they can't afford not to.” From the column:

Everyone earning up to 133 percent of the poverty line, which is less than $15,000 for an individual, gets Medicaid. And the way it does that is by telling states the feds will cover 100 percent of the difference between wherever the state is now and where the law wants them to go for the first three years, and 90 percent after 2020. 

To get a sense of what an incredibly, astonishingly, unbelievably good deal that is, consider this: The federal government currently pays 57 percent of Medicaid's costs. States pay the rest. And every state participates.

But, somewhat perversely, the states that get the best deal under the law are states like Texas, which have stingy Medicaid programs right now, and where the federal government is thus going to pick up the bill for insuring millions and millions of people. In states like Massachusetts, where the Medicaid program is already generous and the state is shouldering much of the cost, there's no difference for the federal government to pay.

That is to say, the less you've been doing on Medicaid so far, the more the federal government will pay on your behalf going forward. And that gets to an irony of the health- care law: Red states have, in general, done less than blue states to cover their residents, so they're going to get a sweeter deal under the terms of the Affordable Care Act.

In May 2010, the Kaiser Family Foundation ran the numbers for all 50 states. Of the top 10 beneficiaries -- which I'm defining as the states that get the highest percentage of eligible adults moved to insurance by the Medicaid expansion -- nine of them are states that went for John McCain in 2008. Of the 10 states that get the least help from the Medicaid expansion, eight of them went for Barack Obama. As Alec MacGillis wrote in The Post back in May 2009, “The Democrats' No. 1 domestic policy initiative, universal health care, is likely to help red America at the expense of blue.” [The Washington Post, 7/2/12]

CBPP: “Federal Government Will Assume 93 Percent Of Expansion Costs Over 2014-2022.” A March 28 Center for Budget and Policy Priorities report explained that states will not shoulder a heavy financial burden from Medicaid expansion. The report estimated that the federal government will “bear nearly 93 percent of the costs of the Medicaid expansion over its first nine years.” From the report:

Since its inception, Medicaid has been jointly financed by the federal government and the states, with the federal government currently paying 57 percent of the cost, on average. The health reform law takes a different approach. To minimize the financial burden on states of the Medicaid expansion, the federal government will pay nearly 93 percent of the cost of expanding Medicaid over the next nine years. 

Specifically, the federal government will assume 100 percent of the Medicaid costs of covering newly eligible individuals for the first three years that the expansion is in effect (2014-2016).[2]  Federal support will then phase down slightly over the following several years, and by 2020 (and for all subsequent years), the federal government will pay 90 percent of the costs of covering these individuals. According to CBO, between 2014 and 2022, the federal government will pay $931 billion of the cost of the Medicaid expansion, while states will pay roughly $73 billion, or 7 percent. 

Health reform will likely increase participation among individuals who are currently eligible for Medicaid but are not enrolled. States will receive the regular federal Medicaid matching rate for covering these people -- and CBO's $73 billion estimate of the net increase in state Medicaid costs includes the cost of covering these individuals. The $73 billion equals a 2.8 percent increase above the $2.6 trillion that states are projected to spend on Medicaid over the same timeframe in the absence of health reform (see Figure 2).

The CBPP report illustrated with the below chart and graph:

[CBPP, 3/28/12] 

Research Intern Ausan Al-Eryani contributed to this post.