A half-dozen states are still trying to decide whether to expand Medicaid enrollment within their borders under the new federal health care law, more than three years after the law was signed and a year after the Supreme Court gave them an easy way to opt out.
Indiana, Michigan, New Hampshire, Ohio, Pennsylvania and Tennessee — all save for New Hampshire are led by Republican governors — are still trying to iron out their intentions for the coming year, according to a decision-tracker from the Kaiser Family Foundation.
"Our goal has been to create a plan that would be as close to commercial insurance as possible and that would include more flexibility with cost-sharing," said Alexia Poe, spokeswoman for Tennessee Gov. Bill Haslam, on why the Volunteer State is still mulling the issue.
It's a nationwide debate that could linger for months and years, as undecided states weigh a tempting influx of funds from the federal government against state-borne costs down the road. Other states may revisit their decisions in future years.
The Affordable Care Act did not impose a strict deadline on states to say whether they would accept the expansion of Medicaid, and the new money that comes with it. Seeking to get as much buy-in as possible, the Obama administration has said it will allow states to opt in on a quarterly basis, since current Medicaid law allows states to adjust their plans within that framework.
The open-ended debate contrasts with states' other big decision under Obamacare — whether to create state-based exchanges where uninsured Americans can buy coverage, often with government subsidies.
States could either set up the exchanges themselves or ask the federal government do it for them, but they had to make their intentions known shortly after the elections last November, because the exchanges are set to begin enrollment Oct. 1.
The federal government had expected most states to accept an expansion of Medicaid until the Supreme Court ruled that states could reject the new part without losing access to existing Medicaid money.
That leaves states grappling with whether potential future budget problems and possible federal strings outweigh the chance to have the federal government pay for 100 percent of expansion through 2016, and 90 percent through 2020.
Twenty-three states and the District of Columbia have opted to expand their programs, but 21 states have declined, citing opposition to Obamacare, suspicion of Washington's promises and state costs down the road, when the federal government scales back its contribution to the program.
Ohio Gov. John R. Kasich, a Republican, had proposed expanding Medicaid but the state legislature balked. Now the state is considering a series of proposals that would resurrect and codify the expansion.
"We do not have a hard deadline," said Sam Rossi, a spokesman for the Ohio Office of Medical Assistance (Ohio Medicaid).
But New Hampshire does. A commission charged with studying Medicaid expansion has to report its findings by Oct. 15.
Gov. Maggie Hassan, a Democrat, criticized state Republican lawmakers in May for rejecting the expansion earlier this year, saying it means "more than 58,000 Granite Staters will continue to go without health insurance."
One month later, she applauded a budget-process compromise that set up the commission.
In Pennsylvania, Gov. Tom Corbett is looking at various reforms to its Medicaid program before it opts for expansion, including a work-search requirement "that will provide incentive for those on our public assistance programs to transition into the workforce and instituting reasonable copays for able-bodied Pennsylvanians," spokeswoman Christine Cronkright said.
The state is also looking at whether it can use the influx of federal funds to help the qualified Medicaid population buy private insurance on the state's exchange, she said, akin to a strategy that Arkansas has pioneered in the last several months.
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