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Arguments Brew at State Level Over Medicaid Expansion

July 5, 2012 at 12:00 AM EDT
Health correspondent Betty Ann Bowser takes a closer look at the arguments over Medicaid expansion and the states that want to opt out rather than take federal money.

JUDY WOODRUFF: And we turn to our continuing coverage of the impact of the Supreme Court’s decision on the health reform law.

The court did uphold the law, but the limits of the decision may affect just how many uninsured American citizens are able to get new coverage.

Health correspondent Betty Ann Bowser reports on that part of the story.

BETTY ANN BOWSER: It was the decision on the individual mandate to buy health insurance that sparked the protests. But the Supreme Court also ruled on another part of the federal health care reform law that hasn’t drawn as much attention, the expansion of the current Medicaid program to cover millions of other people who currently have no health insurance.

Medicaid is a joint federal and state program that provides health care for children, the elderly and disabled, people whose income is so low, they can’t afford to buy coverage.

But Kaiser Family Foundation vice president Diane Rowland explains, under the Affordable Care Act, millions of people who are currently ineligible will be covered.

DIANE ROWLAND, vice president, Kaiser Family Foundation: What happens under the Affordable Care Act is that large numbers of childless adults who are very poor and have previously been uninsured would qualify for coverage.

BETTY ANN BOWSER: That could be up to 17 million people, many of them with incomes below $15,000 a year.

The Supreme Court left it up to the states to decide if they want to buy into the expanded program. And it said, if states choose to opt out, they can’t be financially penalized by Washington.

The expansion is aimed at people like 29-year-old Miriam Aguila, a part-time accountant who suffers from chronic rheumatoid arthritis. Aguila is caught in a catch-22-like situation, unable to work full-time, but making too much money to qualify for Medicaid in Virginia.

MIRIAM AGUILA, part-time accountant: It’s the worst, because I can’t work. I don’t have the resources to get treated for what I have. And I can’t work full-time because I’m sick. So it’s a downward spiral, if you will, and there’s — sometimes it just looks like there’s no light at the end of the tunnel.

BETTY ANN BOWSER: For now, Aguila gets care at a suburban Washington health clinic that takes all comers, insurance or no insurance. But under the expansion, she could qualify for coverage.

Aguila’s doctor, Basim Khan, says 80 percent of his patients are like her, with no health insurance.

DR. BASIM KHAN, Alexandria Neighborhood Health Services: By and large, these patients are the working poor. They work low-wage jobs, long hours, and they just — and for small businesses, and don’t happen to get health insurance with it.

BETTY ANN BOWSER: And Dr. Khan says that’s just the people he knows about in Northern Virginia.

DR. BASIM KHAN: There are about 150,000 people that are uninsured. The safety net can only accommodate a limited amount of these people. So the rest of them actually go without even basic primary care. And a lot of us, as doctors, not just me, but people working in emergency rooms, see the effects of that.

BETTY ANN BOWSER: For the states that decide to opt into the Medicaid expansion, here’s how it will work.

Starting in 2014, the federal government will pick up 100 percent of the cost. Then, in 2017, the government’s share starts to ramp down, so that by 2020 moving forward, Washington will pay 90 percent of the tab, with states picking up the other 10 percent.

But a number of Republican governors are balking at that, saying even 10 percent could bust their already troubled budgets. Virginia’s Bob McDonnell hasn’t made up his mind about the expansion yet, but like a number of other Republican governors, he doesn’t like it.

GOV. BOB MCDONNELL (R), Virginia: All the things it was sold on, that it is going to save money, false, that it is going to create more choice and opportunities for people, false. It is a pig in a poke.

BETTY ANN BOWSER: McDonnell has plenty of company. Medicaid is the single biggest expenditure in most state budgets already, so some Republican governors are just saying a firm no.

Louisiana’s Bobby Jindal is one of them.

GOV. BOBBY JINDAL (R), Louisiana: Look, federal dollars aren’t free. Those dollars are coming from us, from our children, our grandchildren. We’re borrowing money from China to spend on government programs we can’t afford.

BETTY ANN BOWSER: If governors like Jindal stick to their guns, it’s it’s estimated that more than four million people will remain uninsured and unable to qualify for Medicaid.

And critics like George Washington University economist and law professor Neil Buchanan thinks the governors are shortsighted.

NEIL H. BUCHANAN, George Washington University: To me, that just sounds like scare-mongering, because what they’re doing is they’re using what everybody understands is a very unfortunate and severe, but temporary budget crunch to justify not spending money in the future after the budget crunch is over.

JOE ANTOS, American Enterprise Institute: It’s a money issue. They don’t have the cash.

BETTY ANN BOWSER: Health policy analyst Joe Antos of the conservative American Enterprise Institute says the states are going broke.

JOE ANTOS: This is a real issue for state governors to decide on. Do they expand? Do they take advantage of the generous terms that Medicaid is being offered to them for the first three years, only to pay potentially billions of dollars more over the next 10 years? That’s a tough question to answer.

BETTY ANN BOWSER: Dr. Khan thinks opponents of the expansion are missing the point.

DR. BASIM KHAN: I think the question here, and, frankly, the question with health reform in general, is whether states like ours, or whether we as a society, find it acceptable for people in our communities to not be able to see a doctor just because they recently lost their job, just because they have a preexisting condition, or just because they happen to work in a job where — that doesn’t provide health insurance.

BETTY ANN BOWSER: Kaiser’s Diane Rowland thinks, when the politics of the moment settle down, the governors will take the money and buy in.

DIANE ROWLAND: I think, at the end of the day, states will have to take their political concerns and balance them against their fiscal imperatives and balance them against the goal of this program, which is to provide broad coverage to millions of uninsured individuals in their states.

It’s a political calculus vs. a fiscal and human calculus.

BETTY ANN BOWSER: Obama administration officials agree. They say even governors who don’t like the Medicaid expansion will find it hard to walk away from billions of federal dollars.

But with or without all of the states, the program begins in January of 2014.

JUDY WOODRUFF: On our website, check out an interactive map to find out how many people could be affected by the Medicaid expansion in your state.