In states that reject the Medicaid expansion, some lower-income residents who work could find themselves in a coverage gap between the extremely poor and the middle class. The health care law offers tax breaks to offset the cost of private insurance purchased through new online marketplaces for those whose incomes are above the poverty level. But there are no breaks for many others who earn below the poverty level but still aren't considered poor enough to receive Medicaid. The law assumed they would be covered by an expanded Medicaid program.
Bunnie Gronborg, 64, of Festus, Mo., said she has two sons in their 30s who are single fathers who lost construction jobs and now lack health insurance. She had hoped they could be covered by the Medicaid expansion, and she doesn't buy the explanation that the state cannot afford it.
"There's absolutely no reason" to reject the expansion, "except being vindictive and playing political games with people's actual health care," Gronborg said.
Some states have already expanded Medicaid eligibility beyond the standard set in the federal health care law. Others are forging ahead with plans to do so after the Supreme Court ruling.
Minnesota, for example, has already begun drawing more federal money to expand its Medicaid program ahead of schedule. Officials in Connecticut, Iowa, Arkansas and elsewhere said they will move forward with plans to raise their Medicaid income eligibility thresholds, citing the chance to cover hundreds of thousands of additional people with the lion's share of the cost coming for the federal government.
In New Mexico, Republican Gov. Susana Martinez has supported increased state money for Medicaid since taking office last year, though she hasn't decided whether to back the federal expansion to 133 percent of the federal poverty level — an amount equivalent to $14,856 annually for an individual or $30,657 for a family of four. The expansion would add 170,000 people to the state's Medicaid rolls, reducing the number of uninsured New Mexico residents by almost 40 percent.
"I think New Mexico would be foolish not to expand its Medicaid program," said state Sen. Dede Feldman, a Democrat, who is chairwoman of a legislative study committee that deals with health care.
Despite the reluctance of some state officials to embrace the Medicaid expansion, history suggests that the federal government's financial carrot can be a powerful incentive. When the federal government offered enhanced payments to expand health coverage for children in the 1990s, all states eventually implemented the program, said Jennifer Tolbert, director of state health reform at the Kaiser Family Foundation, a nonpartisan informational clearinghouse.
Now states have an even higher-stakes offer to expand coverage for adults.
Even in Florida, which took a leading role in fighting the health care overhaul, officials have not ruled out participating, although Gov. Rick Scott said it is unlikely. Other states are biding their time, too.
"The federal government is putting a lot of money on the table," Tolbert said. "It may be difficult for states to walk away from that money while simultaneously leaving their lowest income residents uninsured."
Associated Press writers Chris Blank in Jefferson City; Jamie Stengle in Dallas; Emily Wagster Pettus in Jackson, Miss.; Grant Schulte in Lincoln, Neb.; Charles Wilson in Indianapolis; David Pitt in Des Moines, Iowa; Chuck Bartels in Little Rock, Ark.; Susan Haigh in Hartford, Conn.; Barry Massey in Sante Fe, N.M.; Marc Levy in Harrisburg, Pa.; Gary Fineout in Tallahassee, Fla.; and John Seewer in Toledo, Ohio, contributed to this report.
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