Many believe states' rejection of the Medicaid expansion is driven largely by election-year politics.
"This is a way in which they're signaling continuing opposition to the Affordable Care Act," said Leighton Ku, professor and director of the Center for Health Policy Research at George Washington University.
States are also balking over the anticipated cost of the expansion. While the federal government would pick up 100 percent of the cost of covering new Medicaid recipients in the first three years, its share gradually declines in the following years, tapering off to 90 percent in 2020 and beyond.
Virginia Gov. Bob McDonnell, chairman of the Republican Governors Association, has held off on making a firm decision for his state. But in a letter to President Barack Obama on behalf of the RGA's Public Policy Committee, he pointed out that increased Medicaid spending would "crowd out" resources for other priorities, including public education, the environment and infrastructure. Without Medicaid reform, he argued, it's hard to see how expanding the program "would do anything other than put more strain on state budgets and the taxpayers."
Some states also worry that, over time, the federal government will shift a greater share of the program's costs to the states.
"What we really believe will happen is that the states will be put more and more . . . on the hook for all these people that they have added to the Medicaid rolls," said Twila Brase, president and co-founder of the Citizens' Council for Health Freedom, a nonprofit advocate of health freedom and privacy and an Affordable Care Act opponent.
Another concern is that publicity over the expansion will prompt some people who are currently eligible but not enrolled in Medicaid to come into the program, and "they're not free," George Washington's Ku observed.
Under traditional Medicaid matching rules, the federal g
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