Young Adults Cannon Fodder in War Against ObamaCare

August 22, 2013

I thought I’d exhausted my reserves of outrage, but that was before some far right-wing organizations plumbed new depths of outrageousness.

FreedomWorks and allies are urging people to opt out of the opportunity to purchase health insurance through the exchanges that will open in October, thanks to the Affordable Care Act, a.k.a ObamaCare.

The campaign is targeting young adults — and presumably those toward the bottom of the income scale, since most relatively high-earners have employer-sponsored health insurance plans.

Young adults — liberally defined as under 40 — are told they should burn their (fabricated) ObamaCare cards and pay the fine for having no health insurance.

Not to worry, they’re told. You can always get care in a hospital emergency room — or health insurance when you actually need it.

True for the ER. Mostly not for the insurance — unless, as Wonkblogger Sarah Kliff explains, you have a “major change in life circumstances” and manage to have it at just the right time.

What’s meant by “major change in life circumstances” seems not to include having a serious car accident or developing symptoms of diabetes — or a serious mental illness like schizophrenia, which is commonly first experienced in late adolescence or early adulthood.

But FreedomWorks isn’t worried about the well-being of young adults — or older adults either, for that matter.

Its aim is to crash ObamaCare because efforts to kill it outright have failed. Doesn’t mean Congressional Republicans won’t take another stab at crippling it one way or the other, of course.

What with all the talk about defunding and delaying, we’re seemingly heading toward another hostage-taking effort.

Congress has already agreed to a spending package that shorts the U.S. Health and Human Services Department on funds needed to maximize enrollment — more than the agency would have needed if 26 states hadn’t decided to leave the whole exchange business to the fed.

Getting the uninsured — and under-insured — signed up won’t be easy. Only 57% of uninsured Americans even know they will soon have to buy health insurance or pay a fine, according to a recent Gallop poll.

And only 62% of all Americans know that they may be eligible for subsidies to buy it on an exchange, another recent survey found.

It may be especially hard to get young adults into the system. About a quarter think they don’t really need the insurance because they’re “healthy enough.” And many of the much larger number who want it may think they can’t afford it.

Yet everyone agrees that the long-term success of the ACA hinges on getting young adults into the insurance exchange pools. They tend, by and large, to need less health care. So the costs of insuring them offset the costs of insuring older, sicker people, who can no longer be denied coverage or charged inordinate rates.

If there aren’t enough of the healthy sort, insurance premiums will rise, which will drive more of them away, which will drive premium costs up even more. Next thing you know, you’ve got what the experts call a death spiral.

All it would take is 3 million opt-outs and “ObamaCare falls apart for good,” FreedomWorks says. Over-promising a tad, but the administration itself has put a top priority on enrollling at least 2.7 million young adults next year.

It’s nevertheless true that a small fraction — maybe 3% — of young adults who have non-group health insurance now could see premium increases because their incomes will put them over the threshold for subsidies.

The threshold for a single person would be nearly $46,000 if the exchanges were open now. Economist Jonathan Gruber, who helped design the ACA, puts the price tag for these relatively fortunate young people at $1,600-$2,000 a year. And though that may be more than they’re paying now, they’re likely to get better coverage.

FreedomWorks, however, tells all young adults that the health insurance they’ll be able to buy “in most cases will cost more than it’s actually worth.”

I seriously doubt that someone earning upwards of $46,000 a year will decide to risk bankruptcy — not to mention inadequate health care — just because s/he’ll have to pay somewhat more than if health insurers could pick and choose the way they used to.

But the message could resonate with young adults further down the income scale, including the 9 million or so who’ve got no health insurance and and may not know they could get a subsidy to buy it.

Fact of the matter is that health insurance bought on an exchange is a good deal for them. In California, for example, a single minimum wage worker would pay nothing for the lowest cost plan and as little as $44 a month for a plan that’s significantly better.

Declaring freedom from ObamaCare, as FreedomWorks urges, would cost the worker $95 initially, but $250 more in 2015 and even more every year thereafter — something FreedomWork omits from its messages.

The bigger issue, of course, is that no one — not even the so-called young invincibles — can count on freedom from a major accident or illness.

Would the folks at FreedomWorks chose the high-risk course they’re advocating for themselves or their offspring? Of course not.

I hope International Steelworkers President Leo Gerard is right when he says that young uninsured Americans won’t either.

But all concerned parties have a lot of work to do to reach them and bring them into a program that right-wingers are carelessly (in the literal sense) doing their best to wreck.


Medicaid Saves Lives, Though New Study Doesn’t Show It

May 16, 2013

My mother-in-law has just been released from the hospital, where she hastily checked in with what turned out to be a case of pneumonia and a related blood infection.

Serious for anyone, but especially someone like Mom, who’s approaching her 94th birthday.

I’ve been wondering whether she’d have gone to the hospital so fast if she hadn’t had Medicaid to supplement her Medicare benefits.

Would she instead have waited to see if the cough subsided and the breathing got easier, knowing she’d have to cover a deductible — and perhaps “coinsurance,” i.e., a copay — she couldn’t afford?

I doubt this would have crossed my mind if I hadn’t been reading responses to the recently-published study of the effects of expanded Medicaid coverage in Oregon.

As you may know, the researchers compared certain health-related measures for low-income Oregon residents who’d won and lost out in a lottery the state used to expand its Medicaid program.

No seniors like Mom in either group because Oregon, like all other states, provides some Medicaid coverage for all low-income Medicare beneficiaries who’ve also got quite limited savings and other financial assets.

So the researchers were comparing two groups of people between the ages of 19 and 65 — all quite poor, some insured by Medicaid and some with no health insurance.

Not surprisingly, they found that lottery winners used health services more, including for preventive care. Prescription medications as well.

They had virtually no catastrophic out-of-pocket expenses — also significantly less occasion to borrow money or skip paying other bills to pay those for their health care.

More surprisingly perhaps, they had significantly reduced rates of depression. (Any relationship here to relief from plaguing financial worries?)

On the other hand, the researchers found no significant effects on several basic health measures — diagnosis and treatment for high blood pressure and elevated cholesterol levels.

And though Medicaid apparently increased probabilities for diabetes diagnosis and medication, it had no significant effect on a measure used for diabetics’ blood sugar control — at least, not within the study timeframe.

This relatively small, highly technical study has proved a Rorschach test of people’s views of the Affordable Care Act, as a borrowed headline on The Incidental Economist says.

ACA opponents jumped on the findings, of course. The libertarian Cato Institute immediately saw “a huge ‘Stop’ sign” in front of Medicaid expansion.

Washington Post columnist Robert Samuelson found confirmation for his view that the ACA has been “oversold” as a measure to improve health — as indeed, has health insurance generally.

New York Times columnist Ross Douthat concluded that the study tended to support health insurance that covers only catastrophes because more comprehensive insurance doesn’t deliver better health, as ACA supporters said it would.

ACA proponents jumped on the findings too, arguing in part that protection from medical bankruptcy is a good enough reason to expand Medicaid, as the law initially required.

That, however, as they pointed out, isn’t the only benefit the study found. Many references to what one of the researchers called the “astounding finding” on improved mental health.

Some progressives also jumped on opponents for misunderstanding — or perhaps deliberately misusing — the health measure findings.

Kevin Drum at Mother Jones does a nice job here. As he explains, “significant” is used in its statistical sense, not as we commonly use it to signal something meaningful or important.

The study did find “fairly substantial improvements” for measures like high blood pressure, as Drum’s annotations of one of its tables shows. But the sample size was too small for these to meet the statistical test — a 95% confidence level.

Nearly lost in the back-and-forth on the latest paper are some findings from an earlier study by the same research team.

This one looked at several health measures, including what we might consider the most determinative — mortality rates.

Samples were large enough to get statistically significant results because the team was comparing rates in three states that had expanded their Medicaid programs with rates in three  that hadn’t.

Lo and behold, mortality rates went down in the expansion states — by 6.1%. That’s 2,840 fewer deaths a year for every 500,000 people who gained access to affordable health care through Medicaid.

Which brings me back to Mom, who might not be alive if she hadn’t gone to the hospital when she did.

And who probably wouldn’t be back in her own place now if Medicaid weren’t covering the costs of a home aide and a physical therapist to help her get more steady on her feet.

This isn’t statistically significant, but it’s pretty damn significant to me and others who love her.


The Message Behind the Messages in Ryan’s Budget Plan

March 18, 2013

This year I vowed not to pick apart Congressman Paul Ryan’s budget plan — the refurbished, but barely changed Path the Prosperity.

A path it certainly is. And it’s worth attending to because it shows where right-wing Republicans want to take us — if not all at once (highly improbable), then step by step. Or should I say manufactured crisis by crisis?

Specifically, as Washington Post columnist Michael Gerson indicates, they view “civil society as an alternative to government.” This should set off alarm bells among nonprofit service providers and all of us who care about the work they do.

Like last year’s plan — and the plan the year before — it purports to strengthen the safety net by block granting Medicaid and SNAP (the food stamp program), thus giving states “flexibility” to manage increasing diminished federal funds.

Except that they’d have to time-limit SNAP participation, since that worked so well for former — and now desperately poor — families dumped out of the safety net by “welfare reform.”

Retirement would be secured by converting Medicare into a modified voucher program that would jack up the per person cost of traditional Medicare, thus building a fiscal case for killing it.

Meanwhile, seniors would have to pay increasingly more for their insurance because the premium support they’d get from the government wouldn’t keep pace with rising health care costs.

And the Affordable Care Act would be repealed, including the federal incentives for Medicaid expansion. So an estimated 40-50 million more low and moderate-income people too young for Medicare wouldn’t have any health insurance whatever.

Something (unspecified) would be done to cut Social Security spending. The plan cites misleadingly over-simple life expectancy increases. So we can infer that Ryan wants the eligibility age increased again.

Also “less generous benefits.” We know by now that this is code for pegging Social Security cost-of-living adjustments to the chained CPI, which rises more slowly than the price index used now.

But the plan itself merely directs the President and Congress to propose reform legislation — a profile in courage, as one advocate remarked.

But I said I wasn’t going to write about these things. And here I am off on a tear.

The combination of what Robert Greenstein at the Center on Budget and Policy Priorities calls “reverse Robin Hood policies” and the euphemisms used to describe them does that to me.

Well, the Path will die in the Senate, just like the previous plans. So the most we can say about it as a genuine budget blueprint is that it sets the stage of another partisan standoff.

What actually struck me about the plan was the introductory justification — not the lead-off hysteria about the imagined debt crisis, but the celebration of community.

The budget, Ryan says, “makes room for community — for the vast middle ground between government and the person.” People find happiness “through friendship, … in their families, their places of worship and youth groups.”

“While we belong to one country, we also belong to thousands of communities.” They encourage our personal growth. “So the duty of government is not to displace these communities, but to support them.”

Who could argue with that? Only someone, I suppose, who thought that the federal government was — or should be — the source of our personal happiness, sense of “belonging and self-fulfillment.”

The explicit message is that our communities — and our families — face many dangers, i.e., “rising health costs, a stagnant economy, massive debt, an uncertain world.”

The federal government can do something about these, but it shouldn’t play the leading role because its proper business is to “secure our individual rights and protect … [community] diversity.”

The unspoken message is that Ryan and his right-wing colleagues aim to divest the federal government of core responsibilities for the health, well-being and economic opportunities of the population as a whole.

The proposed Medicaid and SNAP block grants wouldn’t merely shift funding responsibilities to the states — by shrinking the federal cost shares over time.

They would ultimately shift feeding and tending to the medical needs of low-income people onto local communities because it’s wholly unrealistic to believe that states would — or even could — continue to absorb the costs of retaining these critical safety net programs intact.

Nor make up for deeper, as-yet-unspecified cuts to non-defense programs that depend on annual appropriations, e.g., education, transportation, public safety, housing assistance.

They’d be billions larger than those the current law requires because the Ryan budget would shift all further mandated cuts in defense to those other so-called discretionary programs.

States could also lose funds for school meals, other child nutrition programs and Temporary Assistance for Needy Families because another $800 billion would be taken from programs that don’t depend on annual appropriations — in addition to those, like SNAP and the major health care programs, that the plan specifically names.

We would, in other words, return to some long ago time when faith-based and other local community organizations cared for the poor in their communities as best they could, with no government help whatever.

Many communities today have strong networks of nonprofit organizations that both supplement and serve as channels for federal spending on both safety net programs and others that meet vital human and economic needs.

But not all communities have such organizations.

And I doubt you could find a nonprofit anywhere that would say that it — and others in its network — could meet the needs of all low-income community members if the federal government backed out of its anti-poverty commitments.

In short, the budget plan presents a clear contrast between the right-wing Republican vision for our society and the vision President Obama campaigned on — that “we are greater together” and that government is a way we come together to help give life to values we commonly share.

Well, most of us anyway.


New DC Poverty and Shared Prosperity Figures Show Uneven Progress

December 3, 2012

Last week, I took a crack at the Half in Ten campaign’s updated poverty reduction and shared prosperity indicators for the nation as a whole. It’s also updated a smaller set for each state and the District of Columbia.

Here then is what we can learn from the new figures for the District.

We can look at these in a couple of ways — in comparison to last year’s or to the same indicators for the whole country. We can also see how the District ranks among states.

But the District isn’t a state. And however much it deserves to be one, comparisons to other large cities rather than to states as a whole would be more appropriate for issues like Half in Ten’s.

So let’s just look at the indicators themselves.

On the whole, we see more progress than backsliding. But — no news to any of you, I guess — the District has a long way to go on both the poverty and shared prosperity fronts.

For some indicators, the progress would be expected.

For example, the official poverty rate for the District dropped, though it was still well above the national rate. Ditto for the unemployment rate.

We see progress that can’t be attributed simply to the improving economy, however. The backsliding calls for other — or at least, more complex — explanations too.

Good Jobs

In addition to the unemployment rate, Half in Ten provides a handful of indicators for the employment prospects of relatively young District residents. Forward movement across the board:

  • The percent of freshmen who completed high school in four years increased from 56% to 62.4%* — far below the nationwide 75.5% rate, but progress nonetheless.
  • The percent of “disconnected youth” dropped by 1%, leaving us with nine out of every hundred youth who were neither working nor in school.
  • The already-high percent of young adults (25-34) with at least a two-year college degree rose to 62.7%.

Stronger Families

The good jobs indicators clearly relate to child, youth and family well-being. Unlike these, the indicators Half in Ten puts in the strengthening families category are a good news/bad news story.

In the good news part, the rate of births to teen mothers dropped from 50.9 to 45.4 per 1,000. Still considerably above the national 31.3 rate, but moving in the right direction.

And the percent of residents without health insurance dropped to 6.9% — well below the 15.7% national rate, which also registered a drop last year.

In the bad news part, the pay gap between men and women workers reportedly grew — and by a lot.** In 2010, it was considerably smaller than the nationwide gap. Last year, it was bigger.

And the rate of children in foster care rose from 18 to 20 per 1,000. Notwithstanding what I said about the rankings, I can’t resist noting that the District’s rate is far higher than any state’s.

Economic Security

Good and bad news for indicators in this category also.

On the good news side, the rate of food insecure District households dropped from 13% to 10.9%, while the nationwide rate rose.

And the percent of jobless District residents who received unemployment insurance benefits shot up from 36.3% to 64% — at least in part due to program reforms the District adopted to get its share of the reward money offered by the Recovery Act.

On the bad news side, the percent of District households without bank accounts — a measure of asset-building capacity — rose from 24.4% to 41%.

Might the marked increase have something to do with the new fees banks are charging — or their higher minimum balance requirements?

One economic security indicator that looks very positive is, I think, misleading.

We’re told that the number of rental units for very low-income households increased from 53 to 77 per hundred — almost 20 more than the nationwide rate.

How could that be when we know we’ve got an affordable housing  crisis here?

The answer lies in the U.S. Department of Housing and Urban Development’s definition of “very low-income,” i.e., at or below 50% of the median income for families in the area.

The area HUD carves out for the District includes nearby suburbs populated by very well-off folks.

A median income for the District alone would put more units out of reach — even more if Half in Ten had linked its indicator to “extremely poor households,” i.e., at or below 30% of AMI.

Half Full, Half Empty and Now What?

So we’ve got progress on more indicators than not. But we’ve still got well over 109,000 poor District residents and lots more who aren’t getting a share of that prosperity that parts of our envisioned One City enjoy.

Our local officials could move some indicators in the right direction — or further in the right direction.

But much depends on what Congress decides to do about tax revenues and spending cuts in whatever bargain emerges to pull us back from the so-called “fiscal cliff.”

________________________________________

* These figures are for the 2007-8 and 2008-9 school years. After Half in Ten published its update, the U.S. Department of Education released high school graduation rates for 2010-11. These are the first set to reflect a standardized calculation method for all states.

The District’s on-time graduation rate was 59% last year. This, at the very least, raises questions about the prior progress shown.

** The wage gap figure Half in Ten provides is significantly greater than the gap reported by the American Association of University Women. Part of the difference derives from how annual earnings are calculated, but there’s got to be some other factor too.


DC Makes Right Choices on Health Care Reform

July 19, 2012

Reading about how states are responding to the Affordable Care Act, I feel proud to live in the District of Columbia.

Only 10 states have decided to expand their Medicaid programs by the 2014 deadline. The District has charged ahead.

It’s already lifted its income eligibility ceiling to 133% of the federal poverty line, as the ACA required — until the Supreme Court in effect said it couldn’t. The District has also requested — and received — a waiver to lift the ceiling to 200% of the FPL.

This is so fiscally smart.

Under a separate program called the DC Healthcare Alliance, the District had been paying the full costs of health coverage for people with incomes below 200% of the FPL who couldn’t qualify for Medicaid.

Now it’s shifted a majority of them from the Alliance into Medicaid. The federal government pays its regular 70% share of the costs. And as of 2014, it will pay 100% of the costs for the newly-eligible at or below 133% of the FPL.

Another cause for pride is the DC Council’s decision to preserve enough funding for the Alliance so that it can still cover hospital-based services for adults who can’t be shifted — mostly undocumented immigrants, we’re told.

Consider that some states are doing their best to drive these people out — most of them among the states that won’t admit even more poor U.S. citizens into their Medicaid programs.

And since I’m beating the drum here, I’ll add that the District has moved ahead to establish an exchange for health care insurance purchases, as the ACA envisions.

Only 14 states have even established the necessary legal framework. Mayor Gray signed the District’s law in January — after what seems to have been a good bit of work by an interagency task force, including efforts to get public input.

Virtually all states have gotten grants to plan exchanges, as has the District. But 17 of them decided to stop or slow down planning until the Supreme Court ruled on the ACA. Another six hadn’t really gotten started.

Now these states are behind the eight ball. If they don’t have a “blueprint” ready by November, the federal government may decide to run an exchange for them — just the kind of “takeover” conservative ACA opponents deplore.

Rhetoric aside, the laggard states may, for various reasons, wind up with a health care system that’s less satisfactory than what they’d otherwise have.

Six states have nevertheless decided not to even try to establish exchanges. Seems we’ve got a new legal strategy for making the health reform plan crash. Or maybe two.

Some ACA opponents, including a bunch of Congressional Republicans, now claim that the ACA doesn’t allow the federal government to impose penalties on employers who won’t provide adequate, affordable health insurance except in states that operate their own exchanges.

Others argue that the federal government can’t provide subsidies to households who purchase health insurance on exchanges that state inaction constrains it to create.

So we can look forward to more brawling in Congress — and perhaps another round of lawsuits.

But, as things stand now, these attacks on the ACA won’t affect District residents because our policymakers have viewed the law as an opportunity to “ensure  … access to quality, affordable health care” for all of us.

You’d think this would be a no-brainer. It’s a testimony to our times that it’s worth a shout-out.


Supreme Court Medicaid Ruling Worst for Very Poor People

July 5, 2012

Analysts and pundits have dug into the Supreme Court’s ruling on the Affordable Care Act, including the part that addresses Medicaid.

What we’re learning is very bad news for very poor people because millions — especially the poorest — are likely to remain uninsured.

Here’s why.

As I earlier wrote, the ruling essentially lets states retain their current Medicaid eligibility restrictions.

They’d forfeit the extra federal funding they’d get if they expanded their programs to include all residents (except some immigrants) with incomes at or below 133% of the federal poverty line.

But they wouldn’t lose the funding they get under the regular formula — 50% up to 73.4% of costs in the upcoming fiscal year.

We’ve had a lot of speculation about what state governors will do, especially those heading up the 26 states that challenged the law.

Some say it will be hard for them to turn down so much extra money, especially when their constituents see how other states are benefiting — and from their federal tax dollars too.

Governors will also be under pressure from their in-state hospitals — a powerful lobbying force, as the final shape of the ACA shows.

Others point out that some right-wing governors have already rejected extra federal money, e.g., some of the stimulus grants created by the Recovery Act.

And some of their states would incur quite large additional Medicaid costs — not initially, but as 2020 approaches and thereafter. A big reason is that, at this point, their programs exclude so many people an expansion would cover.

In Texas, for example, non-working parents qualify for Medicaid only if their incomes are below 12% of the federal poverty line. The cut-off for working parents is 26% of the FPL — just over $4,960 a year for a family of three.

Not surprisingly then, the combined caseloads for Medicaid and the Children’s Health Insurance Program* would initially increase by an estimated 1.2 million if the state adopts the ACA expansion criteria.

This alone, says the state’s Health and Human Services Commission, would cost the state $2 million, increasing to $1.4 billion by 2020.

What it would get from the federal government would be exponentially larger, however — total of $52.5 billion through 2019.

Florida Governor Rick Scott claims that it would cost his state about $1.9 billion to “implement a massive entitlement expansion of the Medicaid program.”

In this case too, though he doesn’t say it, the cost in part reflects the state’s very low income eligibility cut-off — 58% of the FPL for parents.

Think Progress reports that Scott and nine other governors have said they’ll definitely not accept the expansion funding. Twenty-two are still on the fence, including 15 whose states signed on to the lawsuit.

So it seems we’ll indeed see a goodly number of states with no Medicaid expansion — at least initially. We’ll thus still have millions of people with no health insurance. And they’ll be among the poorest.

The problem, as the Center on Budget and Policy Priorities explains, is the way the ACA structures tax credits to subsidize health insurance purchased on the exchanges states will establish — or the federal government establish for them.

The most generous subsidies are for people at 100% to 133% of the federal poverty line. I infer that Congress included this income bracket to extend assistance with health care coverage to documented immigrants who aren’t eligible for Medicaid.

Other people in this income bracket could purchase health insurance if their state decides not to expand its Medicaid program.

The coverage would cost them more than Medicaid would have, but the premiums would be fairly modest — at most 2% of annual income.

No subsidies, however, for people below the federal poverty line — people who can’t possible afford to buy insurance at market rates. They’re about 80% of all uninsured people who’d have become eligible for Medicaid before the Supreme Court ruled.

Congress could, of course, fix the ACA to make health insurance for these people affordable if their states won’t open Medicaid to them.

Lot of luck. Republican Congressional leaders insist that the law must, as the House Majority Leader John Boehner put it, “be ripped out by its roots” and replaced with …. Well, they’re still not saying.

This much we know. Senate Minority Leader Mitch McConnell thinks that coverage for the well over 30 million people uninsured now “is not the issue.”

As the New York Times explains, Republicans may have difficulty dismantling the ACA in its entirety. But this is cold comfort to the poor people whose only hope for health care is Medicaid.

* CHIP is part of the calculation because Texas had planned to shift some children out of the program and into Medicaid in 2014.

UPDATE: PolitiFact has just awarded a False rating to Governor Scott’s claim that expanding Florida’s Medicaid program would cost $1.9 billion. Estimates from the state’s health care agency, it says, indicate that costs for new patients added under the expansion would be about $500 million, but not until 2020.  At least, one advocacy organization has called the estimates “hyper-inflated.”


Health Care Reform Survives, But With Low-Income People at Risk

June 29, 2012

I don’t know about you, but I breathed a huge sign of relief when the first tweets announced that the Supreme Court had upheld the individual mandate in the Affordable Care Act.

I’d been thoroughly convinced by arguments that the whole ACA framework would ultimately collapse if people could go without health insurance until they needed costly care and then were entitled to it — and at the same price the company charged people who needed only routine preventive care.

What’s problematic, however, is another part of the Supreme Court decision, which may limit low-income people’s access to affordable health care. Here’s why.

Under the ACA, all individuals with incomes at or below 133% of the federal poverty line were supposed to become eligible for Medicaid in 2014, when the health insurance purchasing exchanges and subsidies for not-so-low-income people also kick in.

All, that is, except undocumented immigrants and others who’ve been in the country for less than five years.

The federal government will initially pay the full costs states incur for Medicaid caseload increases due to the higher eligibility ceiling and the expansion of coverage to adults who don’t qualify now, e.g., those without disabilities or dependent children.

The extra federal support will phase down after the first three years. Beginning in 2020, states will get only 90% of coverage costs for their newly-eligible Medicaid participants.

Still a high percent, but likely to leave them with a total of about $73 billion more to pay by 2022.

Or maybe less. As the Center on Budget and Policy Priorities notes, this estimate doesn’t factor in what state and local governments will save in health services for the uninsured, e.g., emergency room care.

Twenty-six states nevertheless filed a lawsuit claiming coercion because, under the law, they’d lose all federal funding for their Medicaid programs unless they expanded them as described.

This is really no different from the way a vast number of federal programs operate. If states want federal funding, they have to meet certain standards.

For safety net programs like Medicaid, this generally means that they have to provide certain types of benefits to people the federal law has targeted.

The Supreme Court majority, however, ruled that states can opt out of the Medicaid expansion without losing their regular share of Medicaid funding.

It seems reasonable to suppose that many, if not all of the 26 states will do just that.

Other states might follow, since they’ve been struggling with rising Medicaid costs — and paring back optional benefits — since the recession set in.

What’s going to happen to the millions of uninsured people who aren’t poor enough to qualify for Medicaid under their states’ existing laws, but plenty poor enough to make market-rate health insurance policies unaffordable?

To the able-bodied, childless adults, some of whom are poor as the proverbial church mouse — homeless even?

Well, maybe this is an idle worry. As economist-blogger Jared Bernstein observes, anti-poverty advocates won’t be the only ones fighting against state opt-outs. Health care providers have interests in Medicaid expansion too.

Mother Jones blogger Kevin Drum thinks that some state agencies will also press for expansion since they’re “already on the hook for indigent healthcare.” Better to get those indigents into Medicaid and the federal government picking up the costs.

On the other hand, Wonkblogger Ezra Klein reminds us that the Supreme Court decision is hardly the end of the story.

Both Congressional Republicans and Presidential candidate Mitt Romney have vowed to repeal the ACA.

Say they’ll replace it, but can’t (or won’t) tell us how. Clearly, however, not with anything like an individual mandate or a mandatory expansion of Medicaid.

An across-the-board sweep in November, including a 60-vote Republican majority in the Senate, could thus put us right back where we were before the ACA.

As many as 33 million people who would have had health care coverage — including as many as 17 million through Medicaid — would still be at risk of untreated illnesses and injuries or bankrupting medical costs.

One reason that 2012 is, as an op-ed in the New England Medical Journal says, “a watershed election for health care.”


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