In issuing their ruling over the constitutionality of the Patient Protection and Affordable Care Act (ACA), the United States Supreme Court has created an entirely new variable regarding the nation’s health care reform efforts.
Specifically, in finding that the federal government cannot compel states to expand their Medicaid programs to include all those earning less than 133 percent of the federal poverty level (FPL) by threatening to withhold existing Medicaid funds, the court has created a scenario in which state leadership can opt out of the expansion without fear of penalty.
This begs the question: Who’s in and who’s out in terms of Medicaid expansion?
For starters, it’s important to realize that the answer to this question is still evolving. Many states are still attempting to digest the court’s recent ruling, or are awaiting further federal guidance in light of the new circumstances.
There have, however, been some states quick to announce their intentions.
In California, Secretary of Health and Human Services Diana Dooley has noted that the Golden State will be moving forward with the Medicaid expansion, as have governors or representatives from Washington, Minnesota, Illinois, Vermont, Massachusetts, Connecticut, Maryland, Delaware and the District of Columbia.
Meanwhile, Texas, Louisiana, Mississippi, Florida and South Carolina have publically announced that they will not be expanding the Medicaid programs in their states. Governors in these states have also noted that they would not be establishing state-run exchanges.
From here, the situation becomes slightly less clear.
States such as Nevada, Nebraska, Iowa, Missouri and New Jersey look likely to opt out of expansion, but have yet to make an official announcement. Meanwhile, Oregon, which has been viewed as a leader in ACA implementation, appears likely to opt in.
As does Arkansas, where, despite not planning set up a state-run exchange, Gov. Mike Beebe (D) is viewing an expansion fully funded by the federal government for the first three years as an offer too good to pass up.
"I don’t want to send [tax money] to Massachusetts and California while ignoring our own people," he told local media outlets.
It’s this notion of "ignoring" a state’s poorest residents that has some experts predicting that all states will eventually opt into the expansion.
For example, Texas, where Gov. Rick Perry (R) has been one of the staunchest critics of the ACA, also possesses the highest percentage of uninsured residents (25 percent) of any state. Meanwhile, the other four states listed as a definite "no" all have uninsured populations making up more than 20 percent of all state residents.
With opting out essentially meaning a state would be leaving its poorest residents high and dry when it came to coverage, it will be interesting to see who sticks to their guns come 2014.