By David Dayen for FireDogLake

It’s true that states could, after 2014, reduce their Medicaid rolls without the potential consequences of losing their entire federal share of funding. But some states aren’t waiting until 2014.

The court, which upheld most of the law, struck down penalties for states choosing not to expand Medicaid. A few states are also trying to go farther, arguing that the ruling justifies cuts to their existing programs.

Within hours of the Supreme Court’s ruling on June 28, lawyers in the Maine attorney general’s office began preparing a legal argument to allow health officials to strike more than 20,000 Medicaid recipients from the state’s rolls—including 19- and 20-year-olds—beginning in October to save $10 million by next July.

“We think we’re on solid legal ground,” Attorney General William Schneider said in an interview. “We’re going to reduce eligibility back to the base levels in a couple of areas,” he said. Maine, like some other states eyeing cuts, earlier expanded its Medicaid program beyond national requirements.

Other states, including Wisconsin and Alabama, are expected to follow Maine’s lead, though there is disagreement over whether the high court gave the states such leeway. That could lead to battles between states and the federal government that could drag the health law back to the courts. New Jersey and Indiana also said they were evaluating the decision and did not rule out challenging the requirements.

This looks to me like an expansion of what the Court actually said. The Court’s ruling specifically regarded tying the Medicaid expansion to the initial program funding as unconstitutional. If the cuts contemplated now started before the expansion, that seems to fall under the same maintenance of effort rules that remain in place until 2014. This will take further litigation and a new ruling to figure out.

But it does show that states view the Medicaid program as something to raid, not something to nurture. They want to push the limits of the ruling to make as many cuts as possible. So suggestions that red state governors will not be able to pass up a “good deal” like the Medicaid expansion doesn’t match with this reality.

Meanwhile, given these statistics out of Texas, it’s not clear whether an expansion will really result in an expansion.

The number of Texas doctors willing to accept government-funded health insurance plans for the poor and the elderly is dropping dramatically amid complaints about low pay and red tape, showed a survey by the Texas Medical Association provided to The Associated Press on Sunday before its Monday release.

Only 31 percent of Texas doctors said they were accepting new patients who rely on Medicaid, the health insurance program for the poor and disabled. In 2010, the last time the survey was taken, 42 percent of doctors accepted new Medicaid patients. In 2000, that number was 67 percent.

Texas doesn’t have enough primary-care doctors to serve the size of the state or its rapid population growth. The doctors’ reluctance to take on new Medicaid patients comes at a bad time, since the new federal health care law proposes adding 6 million additional people to the Texas Medicaid rolls with the intent of ensuring every U.S. citizen has access to health insurance. The state ranks last in the nation in terms of percentage of people insured, with 27 percent of Texans without any kind of insurance, according to a March Gallup poll.

Obviously, having health insurance coverage that 31% of doctors will honor is better than having no coverage at all. But geographic distribution matters here. Texas is a big place, and a low-income resident, on the off chance that the state expands its Medicaid coverage, may not be able to find a doctor for many miles. The primary-care doctor problem is central to this debate. States predisposed to reject the expansion will justify it by saying they don’t have the resources to accommodate all these new eligible patients on the Medicaid rolls.

6 Comments

  1. D Hickey on July 11, 2012 at 12:16 pm

    So no medicaid then WHAT? Who pays for those who have lost jobs, cannot get a job even out of college? We have put on this system many immigrants in our states? Go to an ER in parts of Atlanta and you feel you are in foreign countries? Yes, I am a nurse and believe you take care of all people? See that doctor refuse to take Medicaid how can they do this per their oaths? Now I understand they no longer take an oath? Am I surprised no part of the greed I saw for years in nursing? I became a nurse because I cared? Why I am for a one payer system? Used this in Ireland and Canada works well but we hear negative all the time here to keep the rich health care industry ripping us all off? I compare the system to the Mafia found a legitimate way t o steal? In the end we the ones who have money per working hard in retirement will pay more in taxes for covering the lack of money available per state not taking the money? Keep hearing the mantra do not want the govt in your health care well get to 65 and guess what you are told by your govt what you will pay and what doctors you can see? So unless you are the super rich and can afford these new doctors who are taking care of you good luck? Whole system stinks and yes medicare needs some cut backs and investigation into rip offs abuses I have seen this with many friends and the constant lab ordered and drugs they keep being put on many not needed ? Who is making the money? Stop listening to the pundits on conservative radio I was a fan for years and know as a nurse they are lying through their teeth about Obama care? We need a system for all and it can be done, but the powers that have controlled for so long health care insurance, medical supply, hospitals that make bucks, doctors who can make what they want and refuse patients? Time to stop the greed out here and not listen to what it will do to you and be afraid this is what they are out to do? See this with so many friends who send me e-mails lies of what is going to happen and Supreme Crt decision listen to Rush or Boortz they were in shock with Roberts who turned on them? Not that he realized this was the fair decision to make need health care most of the time you do not plan to get sick or have an accident? Find out the facts and stop listening to those who do not want to lose their profits off the sick, and the politicians in Congress half are millionaires and their buddies are these rich backers in the health care industry including doctors? Ask intelligent people why does Congress have such a good health care plan for themselves and they can get in office one term leave and be covered for health care WHY? I was at my hospital over 20 years and got zero coverage when I left? Now we are attacking teachers, firemen some being told to take minimum wage in Pa. how do you take care of your family but please do not let my house or business burn down? Time for the middle class to say enough already, we need health care coverage for all and we need back our jobs that have been sent out of this country for many to make bigger bucks? WHY was this allowed to happen even Hillary Clinton said she was against? Why did we allow over 20 mill immigrants into this country to take our jobs WHY? Now we give food stamps and health care we the citizen tax payer pay for? I hear the Republicans say why more food stamps now under Obama but who also allowed many of these millions immigrants into our country? I did not hear Bush yell about this? Our border was pretty wide open under him? I stand in grocery lines here in Ga and see immigrants with food stamps? Lets get real on who allowed what when and how? Add up the statistics and not listen to the lies ? I know I voted Republican for 50 years, not anymore they are not for the middle class that I am part of and support? Wake up all of you who worked hard all of your life pay attention I have and know the real truths?



  2. Erica on July 11, 2012 at 12:28 pm

    Totally agree! But all the question marks are throwing me off



    • jake on July 11, 2012 at 3:11 pm

      I agree with Erica — the question marks seem to dilute the message. However, no deaf ears here.

      If a state like Texas continues to remove any safety net for the poor, the unemployed, what exactly is their solution? It is not realistic to just say ‘no’. I guess in some sort of twisted white fantasy, all the poor people leave the state, and suddenly all is well in the Lone Star.

      We need to have a comprehensive system that everyone participates in. The existing health insurance model is based on profit and greed, not health care.



  3. Vashti Winterburg on July 11, 2012 at 5:28 pm

    Here’s a little discussed problem with Obamacare getting more people onto the Medicaid rolls. Many,mostly conservative states, have set the level so low, i.e. below 100% poverty, at which their citizens can qualify for Medicaid, that in order to qualify for the new Medicaid money, those states would have to come up with the matching money to bring all those folks who are below the 100% poverty rate but not on the rolls into the system. In places like Texas we’re talking about billions of dollars. The result is that states like Vermont which already has everyone qualified at the 100% poverty rate level can go ahead and jump on the 100% cost coverage by the Federal Government to add additional participation at up to 138% of the poverty level. Being poor in places like Vermont just got a lot easier than being poor in Texas. Vermont and other, more liberal states are going to end up sucking up a lot of Federal health care dollars and doing right by their citizens.



  4. Deborah Schumann, M.D. on July 12, 2012 at 9:30 am

    According to CMS statistics health care in 2010 looked like this:
    Medicare: 20% of HEALTH CARE DOLLARS covering 14% of people
    Medicaid: 15% of HEALTH CARE DOLLARS covering 17% of people
    Private insurance: 32% of HEALTH CARE DOLLARS covering 54% of people (some estimates say 26% of dollars and 60% of people)
    Out of Pocket: 12% of HEALTH CARE DOLLARS (some estimates say 18%)

    But CMS numbers only add up to 79%. So where is the rest? Administrative costs and corporate profits for the insurance industry?

    The key point here is that TAX DOLLARS and OUT OF POCKET expenditures are paying for MORE AND MORE OF OUR HEALTH CARE while private insurance cherry picks the healthy and makes a profit.

    The Affordable Care Act is inadequate to address the maldistribution and inequity of the current system. The real answer is to pool ALL health care money and create a single payer who will negotiate fees and spend our money wisely.

    By the way, I added up the newly Medicaid eligible populations in states who have already said they will NOT expand with the ACA plan. It adds up to 4 million people. Those states are Texas, Louisiana, Mississippi, Florida, South Carolina, Nebraska, and Iowa. Twelve states have committed to the expansion and the rest are undecided.



  5. Renee Bouvier on August 3, 2012 at 7:07 pm

    The fact that both the healthcare and educational systems have been corrupted, if not eviscerated, will inevitably force many more Americans to become expatriates. I think it is time for the Americans to be held accountable for their actions in the various international institutions, which uphold a certain acceptable level of basic human rights. The Americans in power today in the U.S. should stand trial for human rights violations just like any other government officials from any other despotic, repressive regime. Hey, if it looks like a duck, if it quacks like a duck, if it waddles like a duck, it’s a duck! Stop referring to the U.S. as a modern, industrialized democracy, when it’s not. Perhaps in the 1970s, it was, but not now. The U.S. is just as corrupt and dysfuntional now as the former Soviety Union. Unless something gives, there are many bleak days ahead, which will force many to flee the North American shores of the United States. Many women with lupus have already fled the country — highly educated women from good backgrounds.