How each state will approach health care act

Updated 15m ago

States are sharply divided on how — or whether — to implement the Patient Protection and Affordable Care Act after it was upheld by the U.S. Supreme Court.

The health care law was enacted in March 2010, but its two major expansions of health coverage don't begin until January 2014.
One is the creation of health care exchanges — government agencies or non-profit groups that will organize and oversee a private market for buying health insurance. The exchanges will offer a choice of certified health plans from which individuals and small businesses can choose.

States are expected to establish exchanges or create partnerships with the federal government. If states don't act, a federal exchange is supposed to serve those residents.

In addition, the law calls for a vast expansion of Medicaid, the federal-state health insurance program for the poor and people with disabilities. For the first time in most states, adults earning up to 138% of the federal poverty rate, or $31,809 for a family of four, would be covered.

As passed and signed by President Obama, the law threatened states with the loss of all federal Medicaid funds if they did not expand their programs. The Supreme Court struck down that provision, freeing states to sidestep the expansion without losing other funds.

USA TODAY interviews with governors, top aides and health care officials show some states forging ahead on the law and others are holding back (number in parenthesis is the estimated percentage of people in each state who have no health insurance):

Alabama(16%). "We do not know if the state can afford to expand Medicaid," says Jennifer Ardis, press secretary for Gov. Robert Bentley, a Republican and a dermatologist. "We have serious concerns about the increased costs associated with expanding entitlement programs, but we need to understand the larger implications of the ruling as a whole to determine how many Alabamians might be subject to the Obamacare tax before deciding the best course of action."

Alaska(18%). Gov. Sean Parnell, a Republican, "has directed the state departments of Law and Health and Social Services to review the (court) decision. It may be months before decisions are made on Medicaid expansion and a health care exchange," says Sharon Leighow, Parnell's press secretary.

Arizona(19%). "At this point, the governor has made no decision" on the insurance exchange and Medicaid expansion, says Ann Dockendorff, spokeswoman for Gov. Jan Brewer, a Republican. "We are actively planning to see what role an exchange would play in — and how the ruling will impact — Arizona's health care system." Brewer says, "It is now up to the American people to save our country from the fiscal and regulatory nightmare known as Obamacare. … If Arizonans are to have access to the health care they need from the provider they choose, Obamacare must be fully repealed."

Arkansas(19%). The state will rely on the federal government for an insurance exchange. The state will expand Medicaid services, says Gov. Mike Beebe, a Democrat. "If (working people) have the opportunity to have health care coverage, and if it's going to be paid for by the federal government … I don't know how we leave our people out," he says.

California(19%). The state is "about halfway" toward a Web-based enrollment system to meet the Jan. 1, 2014, deadline for health exchanges, says Diana Dooley, secretary of the state's Health and Human Services Agency. California will expand Medicaid and is expecting a 10% enrollment increase, Dooley says. But California faces a $15.7 billion budgetary shortfall in the 2012-13 fiscal year, according to state estimates. A more than $8 billion tax hike is on the ballot for voters' consideration in November to help close the gap. "If that initiative fails in November, we will have to evaluate what impact that will have on our ability to fully implement the (health care) reforms," Dooley says.

Colorado(14%). The state created a health insurance exchange in 2011, says Lorez Meinhold, senior policy director for Gov. John Hickenlooper, a Democrat. People will be able to begin purchasing insurance in October 2013 for coverage beginning Jan. 1, 2014. "We are creating a Colorado-based system. But we do still need the federal dollars and will go after the federal dollars to build the Colorado exchange," Meinhold says. The state is not waiting for the election and has already begun using Medicaid to cover some people without insurance.

Connecticut(11%). Under Gov. Dan Malloy, a Democrat, Connecticut plans to fully implement the health care act and meet all deadlines. The state already authorized an insurance exchange and expects to runs its own, says Benjamin Barnes, Connecticut secretary of policy and management. The Medicaid expansion could save the state roughly $300 million a year because the state already voluntarily covers some low-income adults without insurance. The new law will let the state expand coverage of adults from the current 60% of the poverty level — for which the state pays 50% of the cost — to 133% of the poverty level while the federal government pays 100% of the costs for the first three years, Barnes says.

Delaware(12%). "We do not plan a standalone state exchange but have been working … toward a federal partnership exchange," says Gov. Jack Markell, a Democrat. "We are still reviewing our options on Medicaid expansion and anticipate further guidance" from the federal government.

District of Columbia(12%). The District plans to implement a health insurance exchange by Oct. 1, 2013, and has already expanded Medicaid. "We will continue to move forward with implementation of this landmark legislation for District residents," says Wayne Turnage, director of the Department of Health Care Finance.

Florida(21%). "Florida will opt out of spending approximately $1.9 billion more taxpayer dollars required to implement a massive entitlement expansion of the Medicaid program," says Gov. Rick Scott, a Republican. The state also won't build insurance exchanges. "Florida already has health care safety net programs for those with the greatest need, including Florida KidCare to ensure no child goes without health care in Florida. … But even though the federal government has promised to initially pay 100% of the increase in Medicaid payments for the first three years of Obamacare, the burden increasingly shifts to Florida taxpayers in future years. Medicaid, which has been growing for years 3½ times as fast as Florida's general revenue, will soon grow even faster under Obamacare, and education funding will be adversely impaired if we do not control the growth in Medicaid spending."

Georgia(20%). "It's far too early to say how we're going to approach the Medicaid expansion," says Gov. Nathan Deal, a Republican. "The court changed the rules of the game on expansion and we'll need to see what the executive branch issues in regulations. … We will wait until the election, which will determine our next steps. However, Obamacare is far too costly for the state with the estimated $4.5 billion in new costs over the next 10 years. … We have to look at the most cost effective ways to increase insurance coverage for Georgians. From the state perspective, it's unaffordable."

Hawaii(8%). "We are planning to fully implement our state-based exchange and the Medicaid expansion," says Gov. Neil Abercrombie, a Democrat.

Idaho(17%). "Obamacare has been bad for America from the beginning," says Gov. C.L. "Butch" Otter, a Republican. "Change is now in the hands of the American people and we must elect a new president and congressional candidates who will repeal Obamacare."

Illinois(15%). The state will work with the federal government to set up an insurance exchange. The state supports expanding Medicaid. "We'll move forward to deliver the benefits of the Affordable Care Act to millions of people in Illinois," says Deputy Gov. Cristal Thomas, a Democrat.

Indiana(14%). "Absolutely no decision has been made to establish a state-based exchange," says Gov. Mitch Daniels, a Republican. "Before a decision can be made, the state needs more information about how a federally based exchange will operate and be funded. … A Medicaid expansion would put 1 in 4 Hoosiers (approximately 500,000 new enrollees) in Medicaid at a cost of approximately $2 billion over 10 years." Daniels says a decision on whether to expand Medicaid will be made by the next governor and Legislature.

Iowa(12%). Gov. Terry Branstad, a Republican, joined the lawsuit against the law "because he calculated that it would cost $800 million for 150,000 new Iowans to join the Medicaid rolls, which is something neither Iowa nor the federal government can afford," says Tim Albrecht, a spokesman. "His goal is to make Iowa the healthiest state in the nation through other methods."

Kansas(13%). Gov. Sam Brownback, a Republican, says no decision on expanding Medicaid or creating an insurance exchange will be made until after the November election. "It's a political question now," he says.

Kentucky(15%). The state will operate its own insurance exchange but has not decided whether to expand Medicaid, says Kerri Richardson, communications director for Gov. Steven Beshear, a Democrat.

Louisiana(17%). "Come this November, we are going to elect a new president and a new Congress who will repeal and replace Obamacare," Gov. Bobby Jindal, a Republican, says. "That's why we have refused to implement the Obamacare health exchange or the Medicaid expansion."

Maine(10%). Gov. Paul LePage, a Republican, says the court ruling "has verified what President Obama has refused to admit all along, which is to say this law is an enormous tax on the American people. The federal government can force you to do or buy anything, as long as they call it a 'tax.' This massive tax hike will only destroy the American economy as it forces us over the financial cliff. … It is now up to the American people to demand full repeal of Obamacare. The Washington, D.C., elites cannot and should not run our lives."

Maryland(13%). Under Gov. Martin O'Malley, a Democrat, the state has "passed legislation to create a health care exchange, setting up standards and regulations to run the program and creating the framework for a marketplace where individuals and small businesses can purchase coverage," says Raquel Guillory, a spokeswoman for O'Malley. Maryland also supports expanding Medicaid.

Massachusetts(5%). Gov. Deval Patrick, a Democrat, expects Massachusetts to fully adopt the federal law and will have to make only small changes in its existing system of universal health coverage, which the federal law is modeled after. The health insurance exchange must reconcile some differences between the state and federal law by 2014, such as the amount of the penalty for not buying insurance and the income levels that trigger the penalties.

Michigan(13%). No state GOP leaders, including Gov. Rick Snyder, have committed to adding roughly 500,000 uninsured residents to the Medicaid rolls beginning Jan. 1, 2014 — despite a federal pledge to pay the full tab the first two years and ultimately 90% of all costs after that. Even if the federal government ultimately pays 90% of the expanded Medicaid costs, Michigan's share could run $200 million annually, according to the Senate Fiscal Agency. Sara Wurfel, Snyder's spokeswoman, says the administration wants to study the cost of expanding Medicaid coverage — in concert with lawmakers — to determine the "best course of action" for the state. State Senate Minority Leader Gretchen Whitmer, D-East Lansing, says she worries that the issue will become mired in a partisan slugfest, perhaps leading the state to miss out on critical federal dollars to help its neediest citizens.

Minnesota(9%). The state will keep planning to develop a health-coverage exchange and to expand Medicaid, says Lucinda Jesson, commissioner of the Minnesota Department of Human Services. Bills have been introduced to create a state exchange, but the GOP-controlled Legislature elected not to pass one. Gov. Mark Dayton, a Democrat, last year extended Medicaid to 84,000 adults earning less than $8,400 a year.

Mississippi(19%). The state is moving to establish a free-market health insurance exchange but will not expand Medicaid, says Gov. Phil Bryant, a Republican. "Even when the expansion is fully funded by the federal government, the state would still have to come up with an additional $110 million in administrative costs to support the 400,000 potential new participants," Bryant says. "I plan to work with conservatives across the county to elect Mitt Romney, so we can repeal and replace Obamacare."

Missouri(14%). "We're just now beginning to review this ruling so that we can understand exactly what it means for Missouri," says Gov. Jay Nixon, a Democrat. "This ruling has significant complexities and implications for families, health care providers and insurers."

Montana(17%). Gov. Brian Schweitzer, a Democrat, says: "We are reviewing the decision. Unlike the federal government, Montana can't just print money. We have a budget surplus and we're going to keep it that way. The federal law means Montana's Medicaid population will double. … Preliminary estimates … indicate an additional 84,000 people will be eligible for Medicaid here by 2019 — at an estimated cost of more than $1.2 billion by the same year. With Montana's share of the bill estimated at $71 million, a new approach to controlling health care costs is needed. There are still a lot of unanswered questions."

Nebraska(12%). Gov. Dave Heineman, a Republican, says: "My biggest concern is that an unfunded expansion of Medicaid means state aid to education for the Omaha, Lincoln, North Platte and Lexington Public Schools and many other Nebraska school districts will be cut. … Cutting funding for the education of Nebraska's children and increasing taxes on Nebraska's families are not my priorities. … Reviewing this decision in a detailed, thoughtful and responsible manner will take weeks and months before a complete determination can be made on what this ruling means for Nebraska."

Nevada(21%). The state is setting up a health insurance exchange and using funds provided in the law to do so, says Jon Hager, executive director of the Silver State Health Insurance Exchange. Gov. Brian Sandoval, a Republican, "does not intend to automatically accept the Medicaid expansion. We will continue to examine (the ruling) to fully understand its implications," says Mary-Sarah Kinner, Sandoval's press secretary.

New Hampshire(10%). Gov. John Lynch, a Democrat, last month signed a law preventing the state from establishing an insurance exchange. That means the state's exchange will be run by the federal government. Lynch says the law "will help provide access to affordable health care to many more of our citizens and help our small businesses with the high costs of health care. The court's decision allows those important provisions to go forward."

New Jersey (5%). Gov. Chris Christie, a Republican, says, "I still believe this is the wrong approach for the people of New Jersey, who should be able to make their own judgments about health care." Christie is weighing whether letting the federal government set up the state health insurance exchange would be a less expensive option, he said on Fox News Channel's Fox and Friends show. He also said he's not sure the state needs to expand Medicaid under the law because the state's program for the poor and disabled already is inclusive. He praised one part of the Supreme Court ruling that pulls back the federal government's ability to force states to expand Medicaid to include people with incomes up to 133% of the poverty level.

New Mexico(21%). The state is developing its own insurance exchange, says Matt Kennicott, communications director for the New Mexico Human Services Department. "There are still a lot of questions that need to be answered and a lot of moving pieces on Medicaid expansion," Kennicott says.

New York(15%). Gov. Andrew Cuomo, a Democrat, has ordered the establishment of a state-based health exchange aimed at the roughly 2.7 million New Yorkers lacking health insurance. The goal is to be ready to accept applications on Oct. 1, 2013. The state also will expand Medicaid. Regardless of the fall presidential election, Cuomo's office says, "New York's planning efforts are focused on implemented the federal law as it stands."

North Carolina(18%). The Legislature did not set up a health care exchange before adjourning this year and Gov. Bev Perdue, a Democrat, is reviewing options, says Chris Mackey, Perdue's deputy communications director. Perdue, who is not running for re-election this year, says it's up to the Legislature to decide whether to expand Medicaid.

North Dakota(12%). The state is not moving to implement the law. "The health care plan is wrong for North Dakota," says Gov. Jack Dalrymple, a Republican. "Our citizens want the freedom to make their own decisions about their health-care coverage. Instead of embracing government-run health care supported by a tax on the American people, we should be pursuing market-based reforms that make heath care more affordable, that encourage greater participation and provide Americans with more choices."

Ohio(14%). Ohio probably will let the federal government create a health exchange for the state, says Lt. Gov. Mary Taylor, a Republican. She estimates the move would save Ohio $43 million. She called a federal exchange rather than a state-run exchange "the lesser of two evils." Ohio is reluctant to expand Medicaid but hasn't ruled it out. John McCarty, state Medicaid director, says Ohio estimates that the health care law will add $369 million to the state's costs in 2014 even without expanding Medicaid, making the state reluctant to take on any other obligations, even if the federal government promises to pay most of the cost.

Oklahoma(18%). Gov. Mary Fallin, a Republican, plans to wait until after the November election to decide how to proceed, according to local news accounts. The Legislature has declined to establish health care exchanges. Fallin hasn't decided whether to expand Medicaid coverage to more uninsured adults, mostly at federal expense.

Oregon(17%). The state is on pace to establish its health insurance exchange in 2013, says Tim Raphael, communications director for Gov. John Kitzhaber, a Democrat. The state isn't waiting for the presidential election to take action. "The governor supports covering the uninsured and changing the way health care is delivered to improve health, provide better care and reduce cost," Raphael says.

Pennsylvania(11%). Gov. Tom Corbett, a Republican, likely will push the state to set up its own exchange because it can do it better than the federal government, spokeswoman Kelli Roberts says. Corbett has not yet decided whether to expand Medicaid. Corbett said after the ruling that the law will "raise health care costs for our families, our employers and our state" but that he would comply and "do all we can to ensure the negative impact of this law affects the lives of Pennsylvanians as little as possible." Corbett "hopes that in November we will have a change in leadership and repeal this law, but what we are focused on is making sure we are doing what is right" in complying with the law, she says.

Rhode Island(12%). The state "has already done tremendous work to establish a (state-based) exchange and plan for Medicaid expansion, says the office of Gov. Lincoln Chafee, an independent. "Rhode Island is committed to implementing Medicaid expansion in order to close the coverage gap and reach nearly universal coverage for all Rhode Islanders."

South Carolina(19%). Gov. Nikki Haley, a Republican, opposes health care exchanges and expanding Medicaid. "We're not going to shove more South Carolinians into a broken system that further ties our hands when we know the best way to find South Carolina solutions for South Carolina health problems is through the flexibility that block grants provide," says Rob Godfrey, the governor's spokesman. The state plans to delay action until after the November election.

South Dakota(13%). "We will not attempt to set up an exchange before the November election," says Gov. Dennis Daugaard, a Republican. "I'm not very enthusiastic about expanding Medicaid. In South Dakota, people still believe in self-reliance, and I think able-bodied adults should be self-reliant. … My hope is that, after the election, the next president and congress will repeal this law."

Tennessee(15%). Gov. Bill Haslam, a Republican, "firmly believes Obamacare should be repealed because it increases the number of people covered by a broken health care system rather than addressing cost issues," says Dave Smith, a spokesman. "The state has been doing preliminary planning for health care exchanges. The governor, in addition to advocating for repeal, believes it is the state's responsibility to be prepared for multiple scenarios" and prefers a state-run exchange.

Texas(25%). Gov. Rick Perry, a Republican, opposes the insurance exchanges and Medicaid expansion, calling them "brazen intrusions into the sovereignty of our state. I stand proudly with the growing chorus of governors who reject the power grab." Texas has an estimated 6.2 million uninsured residents and the highest rate of uninsured among the states. "Neither a 'state' exchange nor the expansion of Medicaid under the Orwellian-named Patient Protection and Affordable Care Act would result in better 'patient protection' or in more 'affordable care,' " Perry says. "What they would do is make Texas a mere appendage of the federal government when it comes to health care." Expanding Medicaid as the law envisions "would only exacerbate the failure of the current system and would threaten even Texas with financial ruin," Perry says, adding that the law's "unsound encroachments will find no foothold here."

Utah(14%). Gov. Gary Herbert, a Republican, says the state may not expand Medicaid. He wants states more involved in setting health care policy. "We have 50 incubators of innovation and policy, who have experience with their own unique circumstances and challenges," he says. "The federal one-size-fits-all mentality is short-sighted and simply bad policy." He says the state will run a "consumer-oriented, market-driven exchange."

Vermont(9%). Gov. Peter Shumlin, a Democrat, supports meeting the requirements of the law for Medicaid and the health benefit exchange. The state is setting up the exchange on its own, with the help of federal funds. Shumlin supports a government-financed health care system covering every Vermont resident.

Virginia(13%). The state challenged the law in court. But Gov. Bob McDonnell, a Republican, also has said the state would comply with the law and has made plans to set up its own health exchange. "If we have to choose between accepting another new federal bureaucratic monstrosity of a federal health-care exchange vs. a state exchange where we can determine what goes in there — if that's the Hobson's choice we are faced with — my inclination is we ought to have a state-based exchange," McDonnell says. "But I think even a state-based exchange is a bad idea. It's more bureaucracy." McDonnell says he worries about the impact of Medicaid expansion on the state's budget and will push to have the law repealed.

Washington(13%). "Our state has already moved to develop a health care exchange. Our governor also supports the Medicaid expansion," says Karina Shagren, a spokeswoman for Gov. Chris Gregoire, a Democrat.

West Virginia(14%). "We're going to review the Supreme Court's ruling, and work with our federal delegation on how we move forward," says Gov. Earl Ray Tomblin, a Democrat.

Wisconsin(9%). Gov. Scott Walker, a Republican who joined the lawsuit opposing the law, says "Wisconsin will not take any action to implement Obamacare. I am hopeful that political changes in Washington, D.C., later this year ultimately end the implementation of this law."

Wyoming(16%). "There are numerous questions that the federal government will have to answer before we can fully understand the implications of the ruling and the state's new options for the Medicaid expansion," says Renny MacKay, a spokesman for Gov. Matthew Mead, a Republican.

How each state will approach health care act