September 11, 2013

Obamacare facts: Medicaid expansion points to new state taxes

July 13, 2012

One way that Obamacare proposed expanding access to health insurance is by an expansion of Medicaid. According to, Congress mandated that the states expand Medicaid to include people within 133 percent of the poverty line as part of the Affordable Care Act. This means that an individual earning less than about $14,856 or a family of four earning less than $30,656 would qualify for Medicaid. Although this mandate was struck down by the Supreme Court, states can still choose to expand their Medicaid programs.

Some leftists have advocated a similar back-door solution to providing a universal single-payer health plan. Instead of passing a new health takeover law from scratch, some Democrats believe that Congress should simply remove the age restriction from Medicare and force all Americans onto the government health insurance rolls.

There are serious problems with the Obamacare mandated expansion of Medicaid or a similar expansion of Medicare. According to the 2012 Medicare trustee report, Medicare’s hospital insurance (Part A) is inadequately funded and will exhaust its trust fund by 2024. Expanding the rolls of Medicare or Medicaid would help speed the programs toward insolvency unless they receive more funding.

Under the terms of the Affordable Care Act, the federal government would pay for the Medicaid expansion in full for the first three years. Afterward, the states would pay 10 percent of the costs while the federal government would pay the remaining 90 percent. The PolicyMic article estimates that there would be between 16 and 18 million new Medicaid enrollees. According to the Kaiser Family Foundation, the average cost per Medicaid enrollee is $7,898. This means that 16 million new enrollees would cost approximately $126 billion per year.

According to Georgia Health News, Georgia’s Medicaid program, which currently covers 1.7 million people, is already facing a shortfall of over $300 million dollars for current recipients. Georgia already spends more than $4.3 billion on health care. This represents 22.5 percent of the state budget and is second only to education in Georgia state spending.

According to the AJC, an estimated 650,000 Georgians would be added to Medicaid. Georgia’s share of the cost for the expansion would be a minimum of $4.5 billion over ten years. As the federal debt rises, Gov. Deal and Georgia lawmakers worry that this number might well increase as Congress shifts more of the financial burden to the states. With the state budget already stretched to the breaking point, the addition of more expenses for the state would require more revenues. This means that the state would probably be required to raise taxes.
"To pay for the expansion without tax increases would require the state to cut nearly a quarter of its annual budget," Brian Robinson, a spokesman for Gov. Deal, told the AJC. "And that's after we've shaved off billions in state spending since the beginning of the Great Recession."
The second major problem is that Medicaid coverage no longer guarantees access to health care. Many doctors are now refusing to accept Medicaid patients because the program’s reimbursement rates are so low. According to the New York Times, reimbursement rates can be as low as $25 for an office visit. This means that doctors often lose money when they see Medicaid patients. The AJC reports that Medicaid reimbursement rates are about 76 percent of those for Medicare, the health program for the elderly. In 2009, even the world famous Mayo Clinic stopped accepting Medicare and Medicaid patients at several of its facilities. The Atlanta Journal’s Kyle Wingfield cites a statistic that 42 percent of Georgia doctors will not accept new Medicaid patients. Nationally, one in three refuses new Medicaid patients and one in four doctors won’t see Medicaid patients at all.

If Medicaid continues to pay below market rates for care, then it will become increasingly hard for Medicaid patients to find doctors. The expansion of Medicaid to vast numbers of new enrollees would make the problem worse by dramatically increasing the numbers of Medicaid patients without increasing the number of doctors who will treat them.

On Georgia Public Radio, Donald Palmisano, Executive Director of the Medical Association of Georgia, agreed.
Palmisano said, ““We do not believe expansion is financially sustainable especially with our state budget looking at a $400 million hole on Medicaid.” He added, ““By expanding another 600,000 additional patients into the system where the system itself does not cover the cost of providing the care, it only makes it that much more difficult for a physician to be able to accept those patients and remain financially viable.”
Several states have already announced their decisions to opt out of the Obamacare Medicaid expansion. Florida led the lawsuit against Obamacare and became the first state to announce its intention to opt out. According to CNBC, South Carolina, Louisiana, Missouri, Mississippi, and, most recently, Texas have also announced their intention to forgo the federal mandate. Twenty-six states were part of the lawsuit so more states are likely to follow. Several governors cited the cost of the expansion in their decision.

In Georgia, which was also a party to the lawsuit, Gov. Nathan Deal told the AJC that Georgia would not make a decision on the expansion until after the elections. Georgia is also delaying the decision on whether to start a health insurance exchange as required by the Obamacare law. If President Obama is re-elected, the General Assembly might be called for a special session to consider those questions.

Georgia’s congressional Democrats recently sent a letter to Nathan Deal urging him to comply with the expansion. Hank Johnson, John Lewis, David Scott, and Sanford Bishop jointly say that “the Medicaid expansion is the right thing to do and it is a good deal for Georgia.” They do offer advice on how to pay for it.

The Medicaid expansion required by Obamacare is certain to be costly to cash-strapped state governments as well as the federal government. Complying with Congress’ mandate will likely require higher taxes or deep cuts to other state programs. The resulting increase in Medicaid patients will also exacerbate current shortages of doctors who accept Medicaid as a form of payment.

Medicare Trustee Cautions States on Obamacare Medicaid Expansion

Medicare Board of Trustees member Charles Blahous released a Mercatus Center report on March 5 recommending states take advantage of the U.S. Supreme Court’s June 2012 Patient Protection and Affordable Care Act (PPACA) ruling by mostly rejecting the law’s Medicaid expansion.

Blahous concluded that states “all appear to face one common, powerful incentive arising from the court’s ruling: to decline to cover childless adults at or above the FPL [federal poverty line] under Medicaid.”
Blahous summarized states’ PPACA Medicaid expansion options in the following flow chart. Click for a full-size version of the image.

Blahous warned that it is not reasonable to count on promised PPACA Medicaid expansion funding given the federal government’s fiscal situation. “In determining whether to expand Medicaid, however, states must also consider the likelihood that federal financing support may ultimately be reduced from current schedules, shifting additional costs to states,” he wrote.

Blahous added, “From a practical perspective, it is quite unlikely that the federal government will make the full amount of Medicaid payments now scheduled under law. The federal government has now run four consecutive years of unsustainable deficits exceeding $1 trillion annually; most influential national policy makers and analysts acknowledge the need for substantial changes to current policies to avoid uncontrolled debt growth in future years.”

Although Governor John Kasich, a Republican, has insisted Ohio must expand Medicaid to help the poor and can roll back the expansion if Washington reduces funding, Blahous wrote, “Medicaid, CHIP, and the ACA’s new health exchange subsidies are leading contributors to the mounting federal fiscal problem, such that it is unrealistic to expect that federal deficits can be contained without these programs’ growing costs being scaled back.”

In his report, Blahous explained the Medcaid program as it stands currently, the vast expansion of the entitlement program written into President Obama’s 2010 health law, and considerations states should weigh when deciding whether to pursue promised PPACA Medicaid expansion funding.

“Through the enactment of the ACA, federal lawmakers sought to considerably expand the numbers of those insured by Medicaid. The ACA added a large category of individuals to those that a state Medicaid program must cover: essentially all those with incomes below 133 percent of the FPL who were not previously eligible. Such individuals were to be covered under Medicaid beginning on January 1, 2014,” Blahous wrote. “With the law also providing for an income exclusion equal to 5 percent of the FPL, the ACA effectively expanded Medicaid eligibility to those with an income lower than 138 percent of the FPL.”

Blahous noted that in early 2012, the Congressional Budget Office (CBO) estimated full Medicaid expansion in every state – forced by a PPACA provision making all Medicaid funding contingent on expanding eligibility – would add 17 million additional Americans to Medicaid.

“In the same report, the CBO projected that the coverage expansion would result in $931 billion in additional federal expenditures for Medicaid and the Children’s Health Insurance Program (CHIP) in the years 2014 to 2022 alone,” Blahous wrote.

When the Supreme Court ruled in June 2012 that existing federal Medicaid funds could not be tied to Medicaid expansion, states were given the freedom to opt out of the PPACA Medicaid expansion entirely or in part.

“Left intact, however, was the ACA’s inducement: the generous federal match rate—100 percent in the first three years and 90 percent over the long term—applied to the Medicaid coverage expansion,” Blahous wrote. “The court’s decision soon brought into focus a critical question: Would all the states aggressively expand Medicaid per the terms of the ACA now that it was no longer compulsory?”

After citing projections that states’ Medicaid expansion costs could amount to between three and four percent of their total Medicaid expenditures through 2020, Blahous wrote, “Either percentage would be small relative to the accompanying increase in federal costs and also relative to states’ total projected Medicaid budgets. But it would be an incremental push in the wrong fiscal direction at a time when many states have been struggling to lower Medicaid expenditures rather than increase them.”

“The interaction of various provisions of the ACA, in combination with the 2012 Supreme Court decision, now renders it unattractive for states to expand Medicaid to cover childless adults with incomes above 100 percent of the FPL. For the population with incomes above this level, there is a straightforward confluence of state interests; states can minimize their budgetary exposure by declining to cover this population under Medicaid, while at the same time providing these individuals access to potentially more generous health insurance coverage.”

Blahous then explained that subsidies provided through PPACA health insurance exchanges will be offered to individuals with incomes between 100 percent and 400 percent of the poverty line. Capping Medicaid eligibility for childless adults at 100 percent of the poverty line could, in theory, result in more flexibility for individuals served by the exchanges while limiting states’ new Medicaid costs.

“States, then, have a substantial incentive to see that their citizens with incomes above 100 percent of the FPL receive services through federally subsidized exchanges rather than through Medicaid,” Blahous continued.

Ultimately, all new federal spending will have to be paid for eventually – and conservative policy experts have pointed out for years that the federal government cannot afford the PPACA exchanges. Nonetheless, capping Medicaid eligibility at 100 percent of the poverty line is the route Wisconsin Governor Scott Walker chose to take.

As Brian Sikma of Media Trackers Wisconsin explained on February 20, 2013, “Placing more people on ObamaCare, as Walker’s program does, further exposes the financial weaknesses of the system. Already, the original Congressional Budget Office estimates for the cost of the federal exchange are being revised upward. Where the money to fund that will come from is not as clear-cut as ObamaCare architects led Congress and the public to believe.”

Why the Obamacare Medicaid Expansion Is Bad for Taxpayers and Patients

The Heritage Foundation
March 5, 2013
Medicaid needs reform, not expansion. This federal–state health care program provides health care to over 60 million Americans and consumes a growing portion of state and federal budgets. Research shows a long history of Medicaid enrollees having worse access and outcomes than privately insured individuals.[1] Due in part to low reimbursement, one in three doctors refuses to accept new Medicaid patients.[2] Despite access issues, Medicaid spending continues to grow. In 2010, total federal and state spending on Medicaid exceeded $400 billion.[3]
Instead of reforming Medicaid, the Patient Protection and Affordable Care Act (Obamacare) expands eligibility to all individuals earning less than 138 percent of the federal poverty level (FPL).[4] The Medicaid program is already struggling to provide care to its core obligations—a diverse group of low-income children, disabled, pregnant women, and seniors. Adding more people further exacerbates Medicaid’s underlying problems.
The expansion of Medicaid fuels a larger trend under Obamacare: government coverage supplanting private coverage. By 2021, 46 percent of all Americans will be dependent on the government for their health care. Of this group, 86.9 million will be on Medicaid/Children’s Health Insurance Program (CHIP), followed by 64.3 million on Medicare and 23.4 million enrolled in government exchanges.[5] This will push U.S. health care closer to a government model.
The Temptation of Medicaid Expansion
Obamacare provides additional federal funding to the states for this new expansion population. Starting in 2014, the federal government would pick up 100 percent of the benefit costs for the newly eligible population for three years. Thereafter, this enhanced federal funding would gradually decline to 90 percent in 2020.
Obamacare also directed states to expand eligibility or risk forgoing all of their federal Medicaid dollars. The Supreme Court, however, ruled on behalf of 26 state plaintiffs that this “all-or-nothing” proposition was coercive. To rectify this, the Court essentially made the expansion optional, meaning that a state could reject the expansion but not lose its existing Medicaid funding.
Today, governors and state legislators are weighing this option as they develop their budgets for the coming year. Proponents use a variety of unrealistic arguments in support of the Medicaid expansion:
  • It provides states with an influx of new, generous federal revenue. This will cause states to spend money that they otherwise would not have spent. Moreover, due to the structure of Obamacare, states will likely have to absorb many currently eligible but not enrolled individuals as well as those who lose their existing employer coverage. These effects would add to the cost.[6]
  • It will result in savings as the cost of uncompensated care declines with expanded coverage. Heritage data analysis shows that in the first few years, when federal funding is at its peak, states may see some savings. Over time, however, in the majority of states, Medicaid spending will accelerate and dwarf any projected uncompensated care savings.[7] These savings are also contingent on states enacting legislation to further reduce uncompensated care funds (Disproportionate Share Hospital [DSH] payments) on top of the $18 billion of federal cuts enacted under Obamacare. Heritage analyst Ed Haislmaier predicts that “governors and state legislators should expect their state’s hospitals and clinics to lobby them for more—not less—state funding to replace cuts in federal DSH payments.”[8]
    Finally, contrary to the theory that expanding Medicaid would cause the number of uninsured to decline and reduce the need for uncompensated care, a similar expansion in Maine found the opposite effect. In Maine, uncompensated care increased, and the number of uninsured in the targeted population (those below 100 percent of FPL) saw limited change.[9]
  • Rejecting the expansion will mean that other states get more. The federal share of Medicaid is based on a formula calculation and actual expenditures. Rejected funds do not go into a general fund for redistribution to other states. The fewer states that expand, the less the federal government spends. States that draw down on these new federal funds fuel the fiscal crisis in our country.
The Trade-Off Dilemma
Committing to an expansion creates a dilemma for the states. To control Medicaid spending, states typically fall back on predictable techniques to manage costs, such as limiting reimbursements to health care providers and limiting services, which ultimately limits access to care. These Medicaid cost controls, however, go only so far. Today, Medicaid consumes over 23 percent of state budgets, surpassing education as the largest state budget item.[10] As Medicaid spending continues to rise, other important state priorities such as education, emergency services, transportation, and criminal justice are squeezed.
Finally, if states resist balancing among spending programs, the alternative is generating more revenues with tax increases. But higher taxes come with a steep price: They reduce economic growth. With most states still experiencing anemic growth, tax increases on top of already higher taxes at the federal level are not an appealing option.[11]
Fueling the Country’s Fiscal Crisis
Any positive assumptions about Medicaid expansion also assume that federal funding remains unchanged. With deficits running over $1 trillion a year, the country’s fiscal future is in need of reform. Federal spending on health care entitlements, including Medicare and Medicaid, is the largest driver.[12]
Even this Administration recognizes that such entitlement spending, including Medicaid, is unsustainable. The President’s fiscal year (FY) 2011 budget outlined several Medicaid reform policies, including setting an across-the-board blend rate for federal reimbursement and limiting the states’ ability to leverage provider taxes for the state share of matching funds. Although the Administration attempts to distance itself from its own proposal, any serious efforts toward entitlement reform must include Medicaid.
In spite of this fact, several Democrat and Republican governors that support Medicaid expansion condition their support on federal funding remaining untouched. In essence, pro-expansion governors are telling Washington, “don’t touch entitlement spending.” This reliance on federal revenues exacerbates the country’s fiscal challenges and could also affect states’ own fiscal health. Recently, Moody’s cited Missouri’s reliance on the federal government, including Medicaid funding, as adversely affecting its credit rating outlook.[13]
Setting Good Policy
There are several recommendations that the states and Congress could adopt to help mitigate the crisis that Obamacare has exacerbated:
  • Reject the Medicaid expansion. Greater dependence on federal dollars tangles the states in bad fiscal policy and bad health care policy. States that reject the expansion avoid relying on unsound federal revenues, stretching an already thin program beyond its means and adding millions to a failing program. 
  • Scale back existing eligibility where possible. Some states have allowed Medicaid to grow beyond its original intent by moving middle-class families into a welfare program. To restore Medicaid as a safety-net program, states should review eligibility levels, scale back eligibility where possible, and restore the program’s focus on its core Medicaid functions.
  • Advance a separate, state alternative. Instead of using a flawed Obamacare model, states should put in place an alternative. States should develop a state solution tailored to the specific needs of this new population rather than placing them in a one-size-fits-all Medicaid option.[14] A non-Medicaid, state-based approach, especially for this targeted population, would give states the control to design policies best suited to addressing the needs of their citizens without onerous Medicaid constraints.
  • Congress should eliminate the federal enhanced Medicaid match. To avoid the argument that states rejecting Medicaid are leaving federal dollars on the table, Congress should level the playing field by removing the new, enhanced federal dollars. This would remove/minimize the temptation of excessive and unsustainable federal funding and restore fiscal constraint at the federal level. States would still be able to expand eligibility but would have to do so with the traditional (non-enhanced) federal matching rate. If Congress ignores this opportunity to restrain federal spending, it could “block grant” the enhanced federal dollars to the states to develop their own state-specific approaches, including alternatives outside of Medicaid.
Alternate Solution Needed
Medicaid is already spread too thin. Adding a new and complex population to this program does not solve its challenges; it only makes them worse. States should resist, and Congress should remove, this temptation. Both should begin to lay out a better and more sustainable alternative than a failing government health program to care for the less fortunate.
—Nina Owcharenko is Director of the Center for Health Policy Studies and Preston A. Wells, Jr., Fellow at The Heritage Foundation.

Fallout for states rejecting Medicaid expansion

The Associated Press
April 22, 2013

Rejecting the Medicaid expansion in the federal health care law could have unexpected consequences for states where Republican lawmakers remain steadfastly opposed to what they scorn as "Obamacare."

It could mean exposing businesses to Internal Revenue Service penalties and leaving low-income citizens unable to afford coverage even as legal immigrants get financial aid for their premiums. For the poorest people, it could virtually guarantee they remain uninsured and dependent on the emergency room at local hospitals that already face federal cutbacks.

Concern about such consequences helped forge a deal in Arkansas last week. The Republican-controlled Legislature endorsed a plan by Democratic Gov. Mike Beebe to accept additional Medicaid money under the federal law, but use the new dollars to buy private insurance for eligible residents.
One of the main arguments for the private option was that it would help businesses avoid tax penalties.

The Obama administration hasn't signed off on the Arkansas deal, and it's unclear how many other states will use it as a model. But it reflects a pragmatic streak in American politics that's still the exception in the polarized health care debate.
"The biggest lesson out of Arkansas is not so much the exact structure of what they are doing," said Alan Weil, executive director of the nonpartisan National Academy for State Health Policy. "Part of it is just a message of creativity, that they can look at it and say, 'How can we do this in a way that works for us?'"
About half the nearly 30 million uninsured people expected to gain coverage under President Barack Obama's health care overhaul would do so through Medicaid. Its expansion would cover low-income people making up to 138 percent of the federal poverty level, about $15,860 for an individual.
Middle-class people who don't have coverage at their jobs will be able to purchase private insurance in new state markets, helped by new federal tax credits. The big push to sign up the uninsured starts this fall, and coverage takes effect Jan. 1.

As originally written, the Affordable Care Act required states to accept the Medicaid expansion as a condition of staying in the program. Last summer's Supreme Court decision gave each state the right to decide. While that pleased many governors, it also created complications by opening the door to unintended consequences.

So far, 20 mostly blue states, plus the District of Columbia, have accepted the expansion.

Thirteen GOP-led states have declined. They say Medicaid already is too costly, and they don't trust Washington to keep its promise of generous funding for the expansion, which would mainly help low-income adults with no children at home.

Concerns about unintended consequences could make the most difference in 17 states still weighing options.
A look at some potential side effects:

—The Employer Glitch

States that don't expand Medicaid leave more businesses exposed to tax penalties, according to a recent study by Brian Haile, Jackson Hewitt's senior vice president for health care policy. He estimates the fines could top $1 billion a year in states refusing.

Under the law, employers with 50 or more workers that don't offer coverage face penalties if just one of their workers gets subsidized private insurance through the new state markets. But employers generally do not face fines under the law for workers who enroll in Medicaid.

In states that don't expand Medicaid, some low-income workers who would otherwise have been eligible have a fallback option. They can instead get subsidized private insurance in the law's new markets. But that would trigger a penalty for their employer.
"It highlights how complicated the Affordable Care Act is," said Haile.
—The Immigrant Quirk

Arizona Gov. Jan Brewer, a Republican, called attention this year to this politically awkward problem when she proposed that her state accept the Medicaid expansion.

Under the health law, U.S. citizens below the poverty line — $11,490 for an individual, $23,550 for a family of four — can only get coverage through the Medicaid expansion. But lawfully present immigrants who are also below the poverty level are eligible for subsidized private insurance.

Congress wrote the legislation that way to avoid controversy associated with trying to change previous laws that require legal immigrants to wait five years before they can qualify for Medicaid. Instead of dragging immigration politics into the health care debate, lawmakers devised a detour.

Before the Supreme Court ruling, it was a legislative patch.

Now it could turn into an issue in states with lots of immigrants, such as Texas and Florida, creating the perception that citizens are being disadvantaged versus immigrants.

—The Fairness Argument

Under the law, U.S. citizens below the poverty line can only get taxpayer-subsidized coverage by going into Medicaid. But other low-income people making just enough to put them over the poverty line can get subsidized private insurance through the new state markets.

An individual making $11,700 a year would be able to get a policy. But someone making $300 less would be out of luck, dependent on charity care.
"Americans have very strong feelings about fairness," said Weil.
Medicare and Medicaid chief Marilyn Tavenner, also overseeing the health overhaul, told the Senate recently that cost is a key question as the administration considers the Arkansas deal. Private insurance is more expensive than Medicaid.
But Tavenner said the Arkansas approach may be cost-effective if it reduces the number of low-income people cycling back and forth between Medicaid and private coverage, saving administrative expenses.
"We are willing to look at it," she said.

ObamaCare's Medicaid Could Insure 21.3 Million Americans in the Next Decade. So Why Do Some States Want to Opt-Out Of ObamaCare's Medicaid Expansion?


ObamaCare Medicaid Expansion is one of the biggest milestones in the health care bill. ObamaCare's Medicaid expansion expands Medicaid to our nations poorest in order cover nearly half of uninsured Americans. The law previously required states to cover their poorest or lose federal funding to Medicaid (federal funding covers 90-100% of the costs) until the supreme court ruling on ObamaCare.

States opting out of the expansion of Medicaid under ObamaCare is projected to drive up insurance costs drastically (check out the facts below), while saving the States relatively small amounts if anything. Join the ObamaCare Facts Mailing List to keep up to date on Medicaid Expansion vote in your state.

ObamaCare MedicaidHistory of ObamaCare's Medicaid Expansion and the NFIB

Unfortunately, when the NFIB took ObamaCare to the supreme court in order to repeal it, the Medicaid expansion requirement was overturned.

Now each state can decide whether or not they want to opt out of expanding coverage to their poorest with no penalty. The new ruling doesn't just hurt Medicaid and ObamaCare, it affects the tax payer by forcing us to pay for states that choose not to help their poorest.

National Federation of Independent Business (NFIB) is an "independent" group that represents "small business". However they historically follow the Republican party line and fight against "entitlement" programs like ObamaCare's Medicaid Expansion that help the nations poorest and the majority of smaller businesses.
Remember the only businesses that pay more under ObamaCare are the top 3% of small businesses and big business.

Learn More About Small Business and ObamaCare

Nearly ONE HALF of uninsured Americans were going to get their health Insurance under ObamaCare Medicaid reform by expanding coverage to the nations poorest starting in 2014. Now states can opt out without losing federal funding.

What is Medicaid?

Medicaid is a joint federal and state funded program that provides health care for over 60 million low income Americans, mostly children, people with disabilities and elderly people who need help or live in nursing homes.

Since Medicaid is a program that works partly on a state level with help from the federal government the rules alter from state to state, but the rule of thumb is that most low-income adults under 65 cannot currently receive Medicaid.

What is "Wrong" With Medicaid

Obamacare opponents use the downfalls of Medicaid as terms to reject Medicaid Expansion. Doctor payouts have been historically low (even lower than Medicare payouts, which themselves are arguably too low). Due to low payouts many doctors don't take Medicaid and the quality of care tends to be poor. However ObamaCare's Medicaid Reforms do a lot to change this.

The ObamaCare Medicaid reforms that come with ObamaCare's Medicaid Expansion include raising the amount doctors get paid to the same level of Medicare (73%) and increasing payments to Medicaid programs that offer preventive services for free or at little cost. New free preventive services include tests for high blood pressure, diabetes, and high cholesterol; many cancer screenings including colonoscopies and mammograms; counseling to help people lose weight, quit smoking or reduce alcohol use; routine vaccinations; flu and pneumonia shots; and others.

The ObamaCare Medicaid Reforms

The ObamaCare Medicaid reforms were meant to expand coverage to up to 21.3 million of our nations poorest. The law had said, prior to the supreme court hearing, that very low-income individuals (those under the 133% FLP line) including adults without dependent children. Even though Medicaid is a federal and state joint program the funding for low income individuals was covered 93% over the next decade by the federal government using tax payer money.

Medicaid Expansion Means, in all States, Individuals with annual incomes up to 133% of the federal poverty line -- currently, $14,856 or less -- are able to enroll. Right now eligibility differs from State to State.

If a state refused to expand coverage then it would lose all of it's Medicaid funds, this was meant as a protection to ensure that states supported their poorest equally. However the NFIB repeal ObamaCare effort worked to some extent and now states are no longer required to insure their poorest under ObamaCare, yet they can still receive the full federal funding for their Medicaid program.

States can now opt out of Medicaid for it's poorest without losing any federal funding.

ObamaCare Medicaid Expansion Opt-Out

The supreme court decided that states have the right to opt of Medicaid for it's poorest without losing any federal funding, this may seem fair or harmless but the implications of this are dire. This will leave many of the nations poorest without health insurance come 2014. ObamaCare Medicaid reform was meant to cover 17 million of our poorest through Medicaid and millions of higher income individuals through Medicare and the Online Health Insurance Exchange Marketplace. Now millions of people may go without health insurance.

Don't Let Your State Take Away Medicaid For Your States Poorest. Vote For ObamaCare Supporters on A State Level.

What Are the Consequences of ObamaCare Medicaid Expansion Opt-Out

If the states decide to Opt-Out of Medicaid expansion, ObamaCare itself will have to step up to the plate and insure these individuals via the ObamaCare Health Exchanges. The problem is that this will likely raise everyone's health insurance, including those with private insurance.

This means that anti-ObamaCare states who reject Medicaid will not only hurt their poorest, it will affect every tax paying American and every American who has health insurance.

What if All States Moved Forward With Medicaid Expansion

If all States Move Forward with ObamaCare's Medicaid Expansion they will collectively pay $76 billion (a 3% increase) to insure up to 21.3 Million individuals who don't have access to health insurance (about half of the nations uninsured) over the next decade. Obviously those who have more to cover will have to spend more. Regardless of what a State Spends the Federal Government Covers 93% of the States Costs. State spending Increases are relatively small compared to what States would pay without ObamaCare or to the 26% increase that the federal government will pay towards Medicaid.

Where the States Stand
ObamaCare Medicaid Expansion Facts

• The federal government will pay a very high share of new Medicaid costs in all states. 100% of costs are cover for the first year. 90% of the spending is done by federal government moving forward.
• Increases in state spending are small compared to increases in coverage and federal revenues and relative to what states would have spent if reform had not been enacted
• ObamaCare Medicaid Expansion sets the eligibility level for Medicaid at 133% FLP, although there is a special deduction to income equal to five percentage points of the poverty level raising the effective eligibility level to 138% of poverty.

The legislation maintains existing income counting rules for the elderly and groups eligible through another program like foster care, low-income

Medicare beneficiaries and Supplemental Security Income (SSI))

• The NFIB helped to change the Affordable Care Act to include a "state opt out" for Medicaid Expansion.
• In combination with ObamaCare's other provisions, if all States participate in Medicaid expansion it would reduce the number of uninsured by 48%, relative to the number of uninsured without the ObamaCare. States with higher uninsured rates prior to the ObamaCare would see larger increases in Medicaid and bigger reductions in the uninsured, compared to states with lower pre-ObamaCare uninsured rates.
•If all states implement the expansion, an additional 21.3 million individuals could gain Medicaid coverage by 2022, a 41% increase compared to Medicaid without the ObamaCare. With many States opting out the number is expected to fall below 15 million.
• Medicaid Expansion covers those who are most likely to use emergency services costing hospitals tens of billions in unpaid hospital bills.
• States will spend little to nothing expanding Medicaid. For example it would cost the State of Florida about $5 a year per person to cover all uninsured below the 138% FLP.
• Low-income families and other Americans who would be eligible for Medicaid will fall between the cracks without expansion (as they do now). ObamaCare will most likely have to insure them in the ObamaCare health exchanges. This is projected to drive up the cost of insurance for all Americans by a great deal.
• Big Business backed groups like ALEC and the NFIB frequently suggest legislation that seeks to dismantle public programs at a state level. They tend to achieve this in Red states where they have the most pull. These states need Medicaid the most as they have the most low-income individuals falling through the cracks. They will also put a bigger burden on everyone else as it will cost more to insure their poorest on the exchange.
• If Medicaid Expansion is Opted out of by too many states it will greatly diminish the effectiveness and affordability of ObamaCare. Stop your state from Opting out of Medicaid by helping to share the ObamaCare Facts.
• The federal government will pay for most (90% - 100%) of the Medicaid expansion when it is implemented in 2014, but states would be required to pay for up to 10% percent of it by 2020.
• Some States, are saying that paying 0% - 10% of the Medicaid expansion as laid out under ObamaCare will cost them too much. While some States will pay more, the increase is very small (3% average increase in Medicaid Spending) even for the States who will pay the most.
• A Harvard case study found that states who had expanded their Medicaid programs from 2000 to 2005 improved health care for the state and saved thousands of lives.
• Some States are expected to save Billions from ObamaCare's Medicaid Expansion.

Which States Will Expand Medicaid under Medicaid Expansion?

Want to know which states will insure the 15 million Americans below the poverty line and which States will leave the rest of the 21.3 million uninsured behind? Find out which states support their states poorest. Want more information on ObamaCare and Medicaid Expansion?

Get the Full KKF Medicaid Expansion Report


  • Alabama*: Gov. Robert Bentley (R)
  • Georgia*: Gov. Nathan Deal (R)
  • Idaho*: Gov. C.L. Otter (R)
  • Iowa*: Gov. Terry Branstad (R)
  • Louisiana*: Gov. Bobby Jindal (R)
  • Maine*: Gov. Paul LePage (R)
  • Mississippi*: Gov. Phil Bryant (R)
  • North Carolina: Gov. Pat McCrory (R)
  • Oklahoma: Gov. Mary Fallin (R)
  • Pennsylvania*: Gov. Tom Corbett (R)
  • South Carolina*: Gov. Nikki Haley (R)
  • South Dakota: Gov. Dennis Daugaard (R)
  • Texas*: Gov. Rick Perry (R)
  • Wisconsin*: Gov. Scott Walker (R)


  • Alaska*: Gov. Sean Parnell (R)
  • Nebraska*: Gov. Dave Heineman (R)
  • Wyoming*: Gov. Matt Mead (R)


  • Kentucky: Gov. Steve Beshear (D
  • New York: Gov. Andrew Cuomo (D)

PARTICIPATING (25 states and the District of Columbia)

  • Arizona*: Gov. Jan Brewer (R)
  • Arkansas: Gov. Mike Beebe (D)
  • California: Gov. Jerry Brown (D)
  • Colorado*: Gov. John Hickenlooper (D)
  • Connecticut: Gov. Dannel Malloy (D)
  • Delaware: Gov. Jack Markell (D)
  • District of Columbia: D.C. Mayor Vincent Gray (D)
  • Florida*: Gov. Rick Scott (R)
  • Hawaii: Gov. Neil Abercrombie (D)
  • Illinois: Gov. Pat Quinn (D)
  • Maryland: Gov. Martin O'Malley (D
  • Massachusetts: Gov. Deval Patrick (D)
  • Michigan*: Gov. Rick Snyder (R)
  • Minnesota: Gov. Mark Dayton (D)
  • Missouri: Gov. Jay Nixon (D)
  • Montana: Gov.-elect Steve Bullock (D)
  • Nevada*: Gov. Brian Sandoval (R)
  • New Jersey: Gov. Chris Christie (R)
  • New Hampshire: Gov. Maggie Hassan (D)
  • New Mexico: Gov. Susana Martinez (R)
  • North Dakota*: Gov. Jack Dalrymple (R)
  • Ohio*: Gov. John Kasich (R
  • Oregon: Gov. John Kitzhaber (D)
  • Rhode Island: Gov. Lincoln Chaffee (I)
  • Vermont: Gov. Peter Shumlin (D)
indicates a state's participation in the multistate lawsuit against ACA
Go Here For Governor's Statements on the Medicaid Expansion

ObamaCare | Cost Of Medicaid Expansion

While states like Florida and Colorado say that a 3% increase in spending is too much, states like Michigan are showing that the States can actually save money by adopting the Medicaid expansion.

The nonprofit Center for Healthcare Research & Transformation projected the net costs of Michigan expanding Medicaid under the health system reform law. In all three scenarios of enrollment uptake assumed by the researchers, the state would reduce both overall spending and the numbers of uninsured residents.
Figures represent the state’s 10-year cost savings, in millions, under moderate projections for the enrollment of newly Medicaid-eligible residents in 2014, the expansion’s first year.
  • $1,861 million: Reduction in non-Medicaid mental health spending
  • $504 million: Reduction in prisoner inpatient medical spending
  • $444 million: Increase in tax revenues from health facilities and professionals
  • $395 million: Savings from elimination of Adult Benefit Waiver program
  • $23 million: Reduction in state employee health spending
  • $3,228 million: Total state budget savings
  • $2,245 million: Gross state expansion costs
  • $983 million: Net state budget savings
Note: Savings amounts do not add up to total savings due to rounding.

Source: “The ACA’s Medicaid Expansion: Michigan Impact,” Center for Healthcare Research & Transformation, October

Who's Eligible Under the ObamaCare Medicaid Expansion

Eligibility for Medicaid Expansion is decided on state by state (typically under the 138% FLP mark). If you live in a state that doesn't want to repeal ObamaCare you are probably safe, however some Red states and swing states should be worried! All legal residents who earn less than $15,302 for individuals and $31,155 for a families of four can receive Medicaid under Medicaid Expansion. People covered under the expansion also include:

• Low income adults with or without dependent children
• Low income children who lose their Medicaid benefits when they are reclassified as adults 19 years.
• Low income adults with disabilities who are not eligible for SSID or SSI.

Has Expanding Medicaid Worked Before?

New York, Arizona and Main expanded medicaid between 200 and 2005. A Harvard study reports, "rates of uninsured residents dropped, access to care improved, and more people reported being in very good or excellent health". The coverage was estimated to save a total of 2,840 lives a year for the states.

Why the ObamaCare Medicaid Expansion Matters

About half of our nations uninsured are in danger of losing coverage on a state level. Letting states Opt out of ObamaCare's Medicaid drives the costs up for the rest of Americans who choose to help their poorest and drives up our taxes and the cost of healthcare. On a human level these low-income individuals won't have access to healthcare and under the current law they wont receive help in the online market place under a certain income (this makes health insurance affordable for the rest of us).

Most of all on a "business" level hospitals and healthcare as a whole will suffer since they will still have to care for these individuals via emergency uncompensated care which will shift even more costs back on us.

The Republican backed NFIB and the anti-Obamacare guys had their day. Lets fight back with our votes and tell them we want ObamaCare and Medicaid for all Americans! Don't let them use state level legislation tactics against an unsuspecting public.

States Opting Out of Medicaid for Their Poorest

The supreme court decision not to repeal ObamaCare (brought to the supreme court by NFIB) says that states can reject Medicaid for their poorest (leaving up to 7% of their states poorest uninsured).

Why would a state want to reject Medicaid? It's because they don't have to reject the funding, they just can opt not to funnel it to poor people. This drives the cost of health care up for the rest of the country and makes ObamaCare less effective.

Who Will Reject Medicaid?

The first states to reject ObamaCare would most likely be the Red states making the Blue states and the Federal Government to carry them on their back. This is already the case with many public programs. The irony is that these are the same states that have the majority of people who call people who receive and need Government assistance.

Big Business Vs. Medicaid Expansion

Big business pays big money to move federal programs to a state level so they can reject portions of the bill they don't like that affect the states they operate in. They use this tactic to degrade the program as a whole and weaken it at a federal level making them less effective. This gives legislators grounds to privatize and dismantle these programs while creating tension between the states themselves.

Moving Government programs to a state level is an age old tactic used by Big Business under the guise of being "Libertarian or Federalist". The true intension is to dismantle popular Government programs like Obamacare and Social Security on a state level via legislation drafted by groups like ALEC.

Protect The Expansion of Medicaid at a State Level

ObamaCare's Medicaid expansion, if it passes in all 50 states, will help half of the nations uninsured get access to health care. If we don't support Medicaid Expansion on a state level our nations poorest will go without healthcare. This will drive the cost up for the rest of us and create a great imbalance between states, tension and unrest. There is nothing that is more damaging to our democracy then dividing the states. If you believe in health care reform, support Obamacare's Medicaid Expansion in your state.
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