Several Republican governors said last week they will not expand their Medicaid eligibility standards to conform to the tenets of the Affordable Care Act. Instead they will utilize an out provided within the Supreme Court's ruling on the ACA's legality (see "SNCJ Spotlight: High Court gives states wiggle room on Medicaid and immigration" in the July 2 issue) that essentially allows states to opt out from opening up their Medicaid roles to millions of residents who have previously been ineligible. Several governors also noted they would continue to resist the creation of state-run health insurance exchanges, preferring instead to wait until after the November presidential election in hope that another historic GOP landslide will lead to the entire law's repeal. Louisiana Gov. Bobby Jindal (R) laid that strategy out during an appearance on Meet the Press. "Every governor's got two critical decisions to make," Jindal said. "One is do we set up these exchanges; and, secondly, do we expand Medicaid? And no, in Louisiana, we're not doing either one of those things." Jindal, who some observers believe may be in contention to serve as presumptive GOP nominee Mitt Romney's running mate, said neither the exchanges nor the Medicaid growth "make sense" for the Pelican State. "I think it makes more sense to do everything we can to elect Mitt Romney to repeal 'Obamacare,'" he added. Similar sentiments have been voiced by other governors, primarily regarding the Medicaid expansion. Wisconsin Gov. Scott Walker, Maine Gov. Paul LePage, New Jersey Gov. Chris Christie, Nebraska Gov. Dave Heineman, Iowa Gov. Terry Branstad, South Carolina Gov. Nikki Haley and Florida Gov. Rick Scott have all indicated they would wait until after the election in November to determine if they will go along with the expansion, which would open up Medicaid eligibility to everyone with incomes up to 133 percent of the poverty level, or just under $15,000 a year for an individual and around $30,000 for a family of four. The federal government is slated to pick up the full tab for that expansion until 2017, in essence making the initial Medicaid growth a no-cost proposition to states. But beginning in 2017, states would have to start paying a gradually increasing portion of the bill, topping out at 10 percent by 2020. But even that relatively small portion could mean significant dollars to states still unsure of their long-term budget security. Texas officials, for instance, estimate that the full expansion would add about 2 million people to their current Medicaid rolls at a cost of around $27 billion over 10 years. Missouri estimates their rolls would grow by 255,000 at a cost of $2 billion over that time frame. Mississippi officials say they would likely see 640,000 new enrollees, costing them $1.7 billion. "Mississippi taxpayers simply cannot afford that cost, so our state is not inclined to drastically expand Medicaid," Lt. Gov. Tate Reeves (R) said. Nebraska Gov. Dave Heineman, the head of the Republican Governors Association, echoed that sentiment, saying Medicaid expansion would lead to major cuts elsewhere. "As I have said repeatedly, if this unfunded Medicaid expansion is implemented, state aid to education and funding for the University of Nebraska will be cut or taxes will be increased," Gov. Heineman told the New York Times. Others, however, including Virginia Gov. Robert McDonnell, Nevada Gov. Brian Sandoval, Texas Gov. Rick Perry, Ohio Gov. John Kasich, Pennsylvania Gov. Tom Corbett and New Mexico Gov. Susana Martinez, have not indicated whether they will back the Medicaid expansion, though they have all voiced opposition to it. Michigan Gov. Rick Snyder is also thought to be supportive of the Medicaid expansion, though he has to date indicated only that he is still reviewing the law to determine a next course of action. But within hours of the Supreme Court decision to uphold the ACA's constitutionality, the governor publicly urged the GOP-controlled legislature to pass stalled legislation to create a Michigan health insurance exchange. Holdout governors are sure to face extreme pressure from health insurance companies, health care providers and advocates for the poor to accept the Medicaid expansion and the exchanges. Henry Ford Health System CEO Nancy M. Schlichting, for instance, said she "absolutely will lobby" Michigan Gov. Snyder for the Medicaid expansion. She said she expected him to support the proposal, though she also noted "he may have trouble" convincing lawmakers. Many observers also believe the lure of federal money will eventually be too much for states to resist. Sara Rosenbaum, a health policy professor at George Washington University, told Kaiser Health News that she expects "the overwhelming number of states" to adopt the Medicaid expansion. But she also cautioned that it could take several years to happen. "The pressure to participate will be enormous from health care providers and communities," she said. "The majority of states will not want to have its poorest residents without coverage." Gail Wilensky, former head of Medicaid and Medicare programs under President George H.W. Bush, also told Kaiser that states often are slow to accept federal Medicaid dollars at first. "Many states have not availed themselves of all the Medicaid money they could have in the past," she said. "However, we also see that when the amount of money or share of expenses gets high enough, states seem to increase their interest." Wilensky also noted that, for all the political posturing of an election year, governors may actually be in a perfect position to accept the expansion. "Republican governors now have political cover to take the money," she told Kaiser. "They can say, 'we have established our right to make our own decisions, so we can expand coverage and get the money or not.'" (KAISER HEALTH NEWS, NEW YORK TIMES, REUTERS, WASHINGTON POST, CBSNEWS.COM, MIAMI HERALD, POLITICO)
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