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Medicaid Expansion: Who's In? Who's Out?

In the week since the Supreme Court upheld almost all of President Obama's health care law, some of the biggest action has been on the Medicaid front, where the administration definitely lost.

Until last week, the Affordable Care Act was expected to drive an expansion of Medicaid to the tune of about 17 million more people being covered over the next 10 years.

The Affordable Care Act, as written, would have required states to provide Medicaid coverage to adults, whether they have children or not, with incomes up to 133 percent of the federal poverty level.

Now that expansion is optional, and it's unclear how many uninsured people will ultimately gain coverage under the law.

Medicaid is paid for with a mix of state and federal funds. So a big expansion could get expensive for states, even though the federal government would kick in a lot of the extra dough.

"It's going to cost Florida $1.9 billion a year," Florida Republican Gov. Rick Scott said on CNBC's Squawk Box Monday. He said Florida wouldn't go along with it.

Scott's claim is too high, according to an independent analysis by Politifact, which put the cost of the additional Medicaid coverage at a little over $500 million a year. And most of those costs wouldn't pop up until 2020.

But five states, including Florida, have said they're out as of Thursday morning, according to The Daily Briefing from the Advisory Board Co.

Lots of states now offer Medicaid only to adults with children, and the income cutoff is generally much less generous, too.

The law says the feds could withhold all federal Medicaid funds from states that didn't comply. But the high court ruled that hammer was just too extreme.

A majority held:

"The threatened loss of over 10 percent of a State's overall budget is economic dragooning that leaves the States with no real option but to acquiesce in the Medicaid expansion."

So the states can skip of the expansion and only miss out on those federal funds that would have gone toward it.

The interactive chart from the Center for American Progress, embedded above with its permission, shows what's at stake. Hover over a state to see how many people could be affected.

As Julie Rovner reported last week, many low-income people who don't qualify for Medicaid now won't be eligible to for the next best alternative, a tax credit to subsidize the purchase of health insurance through a state exchanges.

Rovner is taking another look at how the Medicaid choices are unfolding. Stay tuned.

Copyright 2021 NPR. To see more, visit https://www.npr.org.

Scott Hensley edits stories about health, biomedical research and pharmaceuticals for NPR's Science desk. During the COVID-19 pandemic, he has led the desk's reporting on the development of vaccines against the coronavirus.