• Keep in mind that under the law, any state could start their Medicaid expansion right now if they choose. And this would still be free for the first three years, gradually sliding down to the federal government picking up 90% of the costs. How many states have taken it up? Seven and the District of Columbia. It’s not that high-profile an issue right now, but this shows that Republican governors can, and in fact will, look a gift horse in the mouth.
The seven states, by the way, are California, Colorado, Connecticut, Minnesota, Missouri, New Jersey and Washington. All of them but New Jersey have Democratic governors (that Chris Christie is such a traitor! Actually his legislature forced him into it.)
• Digby perceptively writes that John Roberts achieved what Ben Nelson could not achieve, a state opt-out from the Medicaid expansion. That’s precisely what necessitated the “Cornhusker kickback,” where Nelson got Nebraska a full ride on the expansion forever, rather than the other states, which have it for only three years.
• Added to the fact that states would pick up a minimal cost of expanding Medicaid, Sarah Kliff explains how states could wind up incurring more costs in the functioning of the program:
States could incur significant costs from the expansion. The federal government won’t cover all bills for Medicaid enrollees who were already eligible for the program but never signed up. States worry about those people showing up to enroll, because of all the publicity around the health-care expansion, and having to accept them at the regular match rate.
Meanwhile, the 100 percent match rate doesn’t last forever. After those first three years, the federal government’s match rate starts dropping: It will pay 95 percent of the cost beginning in 2017 and then, in 2020, foot 90 percent of the bill.
States fear that the federal government might decide to ratchet back that number, Salo says. The White House has already shown a willingness to reduce Medicaid spending. Why wouldn’t it rejigger a program that pays for Medicaid at a rate much higher than it has traditionally spent?
There’s no question that this is the fig leaf Republican governors will use in rejecting the program. They will say that the expansion puts them “on the hook” for future costs. And they’re not entirely wrong. For example, Texas wouldn’t only pay $2.6 billion in the years 2014-2019 to accommodate the expansion, which is trivial in the grand scheme of things. They would also see Medicaid costs rise by 3%. And as Kliff writes, “This is all to implement a law that the Texas government sued to overturn.” You really think Rick Perry will go quietly? Texas Health and Human Services Commission chairman Tom Suehs has already said, in reaction to the Supreme Court ruling, “I’m pleased that it gives states more ability to push back against a forced expansion of Medicaid.”
• Austin Frakt is probably right here that, at the least, states will use the opt-out as a bargaining chip to extract concessions in how they handle Medicaid. They may want to privatize certain services, or force more costs onto beneficiaries. That’s what the Roberts ruling can help them do. “It’d be an ugly game, threatening the affordability of coverage of low-income individuals, but that doesn’t mean some states won’t play it,” Frakt writes. Yes, in fact, given the race-based politics at work in many of these states, the fact that it deals with the affordability of coverage of low-income individuals GUARANTEES that this game will be played.
• I checked New Mexico off the list of recalcitrant states this morning, and you may be able to do the same with Michigan:
Michigan Gov. Rick Snyder on Thursday urged lawmakers to work with him to set up an online site where individuals and small businesses can comparison shop for private health insurance now that the U.S. Supreme Court has largely upheld President Barack Obama’s federal health care law.
The Republican governor said in a statement that he didn’t agree with everything in the law, which he says doesn’t focus enough on promoting wellness and restraining health care costs. But he wants to work quickly to set up Michigan’s online marketplace so the state “can make decisions regarding what will be covered as opposed to Washington, D.C., making those decisions for us.”
Snyder said nothing about Medicaid, but going ahead with the exchanges is a leading indicator, IMO.
TPM has a story about several other GOP governors and their early reactions. Louisiana’s Bobby Jindal, Wisconsin’s Scott Walker, and Virginia’s Bob McDonnell seem reluctant to move forward.
This is one of the major stories I’ll be tracking for the next couple years.