In the wake of the Supreme Court decision, states are facing two big tasks:
- Deciding whether to take federal money to expand Medicaid, the joint federal-state health insurance program for the poor and disabled. States are supposed to provide Medicaid to a far larger base – everyone with incomes up to 133 percent of the poverty level, or just under $15,000 a year for an individual.
- Deciding whether to implement their own health insurance exchange, a website to help eligible consumers shop for and purchase health plans, rely on the federal government to do it for them. The federal government will help pay for people to buy insurance on the exchange if their incomes are up to 400 percent of the poverty level.
Three states – Mississippi, California and Texas -- illustrate the range of approaches emerging in the wake of the court’s ruling. Here are the dispatches from NPR member station reporters:
Mississippi, which challenged the federal law, nonetheless has been working for months to build a health insurance exchange, in order to maintain state control of the process.
"It is important to us that we take care of the citizens of this state -- that we have an exchange designed by Mississippians for Mississippians and operated by Mississippians and not by the federal government,” state insurance commissioner Mike Chaney says. “We do not think that one size fits all is the right way to go. What will work in New York state or California may not work in Mississippi."
Some estimate that 275,000 Mississippians will be eligible to buy insurance through the exchange.
But the future of adults who don't make enough money to buy insurance on the exchange is murkier. Many of them would be eligible for Medicaid benefits if the state chooses to expand its coverage.
The cost to the state maybe too much to bear, says Gov. Phil Bryant, a Republican who thinks the state should consider opting out of the Medicaid expansion. "We will certainly seek opportunities that the state will have to reduce the welfare cost to Mississippians. If you look at adding 400,000 (people) that certainly will damage this budget beyond repair," he claims.
The state's lieutenant governor also believes the state should opt out, warning that expanding Medicaid could ultimately cost close to $2 billion dollars.
Other estimates put the price tag at a fraction of that amount, closer to $400 million.
Roy Mitchell of the Mississippi Health Advocacy program thinks politicians are cherry picking the highest possible cost estimates to oppose the expansion. "State lawmakers and policy makers should be looking at the impact and the benefits," he says. "The increased state cost that Mississippi will have to pay to expand Medicaid will be largely, if not completely, offset by the state and local revenue generated by the new federal funding and its related spin-offs by the reductions in uncompensated care costs."
The Mississippi Hospital Association also supports a Medicaid expansion, saying hospitals cannot be expected to treat so many people with no hope of being paid. It predicted that without the expansion, hospitals would be forced to close, leaving many poor Mississippians in the lurch.
-- Jeffrey Hess, Mississippi Public Broadcasting in Jackson
The Golden State is enthusiastically moving to implement both the Medicaid expansion and the health exchange called for by the health law. In fact, after the law passed in 2010, it was the first state to get going to build an exchange.
Peter Lee is in charge of it, and he never let uncertainty about the Supreme Court decision slow him down: "We’ve been staffing up, we’ve been hiring people, we’ve been putting in place, in essence, all of the building blocks to expand coverage for Californians," he says.
Lee left a job in the nation's capital to launch the California system, and says he "came home to California to be just thrilled by the amount of excitement and engagement that I’ve seen in every part of the state in making this exchange work."
And there's a lot of work to do. Lee has to build a web system from scratch, and get insurance companies ready to offer new plans. He needs to recruit and train tens of thousands of people to help with enrollment, and launch a huge marketing campaign.
Anthony Wright, of Health Access California, is pushing hard to keep the effort on track. "We can't let this be like previous programs where it starts slowly and builds gradually over time. We don't have that luxury. Our biggest obstacle is the clock. We don't have a lot of time.”
Millions of Californians will be eligible to buy health insurance through the exchange. And Wright believes it needs as many people under its umbrella as possible on Day One in 2014: "Those who sign up the quickest will be the sickest, but it's going to work best if we have as many people signed up so we can spread the risk and the cost, so that makes premiums lower for everybody."
The longer the exchange goes without broad enrollment, Wright says, the more the state loses out on federal dollars, and the more uninsured people may be living sicker and dying younger. The scope of the job is a challenge. One in five Californians is uninsured.
"Hopefully we can show that if California can do it given how diverse the state is, given how big the state is, given the size of the uninsured population, then that can prove that it can be done in any state,” he says.
California is also moving aggressively to expand its Medicaid coverage. It didn’t wait for the court ruling, launching a demonstration project last year with federal backing that has enrolled more than 400,000 low-income Californians in county health programs.
"We're really testing out what the ACA is designed to do, which is get care, primary care, to these childless adults," according to Farrah McDaid-Ting, of the California State Association of Counties. She adds: "It costs a lot of money to treat someone who has a chronic condition who shows up in the ER [emergency room]. If we can treat that person and get that person under control with primary care, I think it will in the long run save taxpayers money."
The federal government is providing almost $3 billion dollars towards this state effort to prepare California for the Medicaid expansion in 2014.
-- Pauline Bartolone, Capital Public Radio in Sacramento
In Texas, where one in four people is uninsured, the state’s leadership has been vociferously opposed to the federal law and the Supreme Court decision didn't change that. Gov. Rick Perry, a Republican, calls the ruling is a “stomach punch to the American economy.”
He called the law itself a “monstrosity.” And Attorney General Greg Abbott says he’s not giving up the fight.
“I am against this tax and I will work with the state of Texas and members of Congress to repeal this unprecedented tax imposed on Texas,” Abbott declares, referring to the penalty the law will impose on those who fail to buy health insurance starting in 2014.
Neither man has described how Texas will implement the law. So far, the state has taken no official action to set up a health insurance exchange. Nor is it entirely clear what it will do about the optional Medicaid expansion.
“I am a little nervous,” says Katy Caldwell is executive director of Legacy, a safety-net clinic near downtown Houston. “We are not known for our great Medicaid benefits." Along with other advocates, Caldwell is hatching plans to lobby the legislature when it convenes in January.
Since Medicaid is a state-federal partnership, if Texas opts in, the state could pull in $164 billion of new federal money over the first decade.
“It’s shocking to me that we would turn down that amount of money and assistance from the federal government to provide something as basic as healthcare,” Caldwell says
Some estimates say about 1.4 million uninsured Texans could gain health coverage under the Medicaid expansion alone.
In the meantime, some Houstonians are still absorbing what the court ruling means for each of them.
Scot More has insurance right now, through his job working with the homeless. "I’m actually shocked. But, pleasantly shocked. I totally expected them to throw everything out, or at least big chunks."
More is HIV positive and says the court decision upholding almost all of the federal law guarantees that even if he loses his current coverage, other insurers won’t be able to reject him for his pre-existing condition. "You know, I, personally, am getting really tired of who I am and my health being a political tool. You know, I’m a person, not a policy," he says.
-- Carrie Feibel, KUHF in Houston.
Updated on July 3 to correct the estimate for Texas's share of new Medicaid funding.
These stories are part of a partnership with NPR, its member stations, and Kaiser Health News.