Medicaid matters to the poor (photo: freidmanlynn / flickr)

The Supreme Court ruled that states can’t be forced to expand Medicaid with the threat of losing their current Medicaid money. This makes it easy for states to choose to opt in or opt out of the Medicaid expansion provision in the Affordable Care Act, which would expand coverage to everyone up to 138 percent of the poverty line. While people above 100 percent of the poverty line would still be eligible for exchange subsidies, those below it could be left in an insurance no man’s land.

The Urban Institute has crunched the numbers and found that theoretically as many as 11.5 million could lose access to insurance if all the states choose to opt-out of the expansion. From the Urban Institute:

Of these 15.1 million uninsured adults who would be newly eligible for Medicaid under the ACA, 3.6 million have incomes between 100 and 138 percent of FPL, meaning they could qualify for exchange subsidies if they do not have access to affordable employer-sponsored insurance and are not eligible for Medicaid (Exhibit 2). However, even among those who do qualify for exchange subsidies and take up that coverage, the greater cost-sharing requirements for exchange coverage than in Medicaid means that these adults will experience greater financial burdens associated with meeting their health care needs.
Moreover, fully 11.5 million of the newly eligible uninsured adults have incomes below the poverty level and thus would not be able to qualify for federally subsidized exchange coverage (exhibit 2). Of these 11.5 million, approximately 1.4 million live in California, 1.0 million live in Florida, and 1.3 million live in Texas. These uninsured adults would not receive any additional help obtaining health insurance coverage under the ACA if their state does not expand its Medicaid program.

Obviously the number of people who will be actually affected is going to be less than 11.5 million since several blue states such as California have already made it clear that they will take part in the Medicaid expansion. The report, though, provides a solid look at potential size of the problem and how many people are at risk of not getting coverage in each state.

Already several governors, like Florida Gov. Rick Scott (R), have made it clear they will not take part in the expansion. In Florida the failure to expand Medicaid could result in roughly a million people not getting insurance.

While some on the left are banking on the idea that in the end the Medicaid expansion will be “too good of a deal” for local Republican politicians to refuse, it would seem the only way to really guarantee these millions get insurance is to fully federalize the program. Since the federal government is funding the vast bulk of the cost of the expansion anyway, there is no reason to leave it to the whim of local politicians.