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After Supreme Court ruling, Medicaid expansion faces uncertainty

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The law will still call for a big increase in federal spending on Medicaid, as much as $930 billion during the next decade to insure Americans whose income is 1.33 times the official poverty level or lower. But how many new people are enrolled under this plan will depend on whether states opt in.

"We are concerned many states will choose not to expand coverage," Bruce Siegel, president of the National Association of Public Hospitals and Health Systems, said Thursday in a statement released following the court's decision. "In the 26 states that participated in the federal lawsuit, more than 27 million people have no insurance," he added, and many of those who would have been eligible for Medicaid in 2014 "might no longer have that option."

His association represents so-called "safety-net hospitals," which serve a high percentage of poor patients and get significant funding through Medicaid.

States that challenged the Obama law include many in the South, Midwest, Great Plains, and Rocky Mountain region. Whether they opt out of the law remains to be seen. The vast sums of money that the federal government would be sending to the states to cover the Medicaid expansion create significant incentives to participate.

Republican governors didn't commit to a particular position on the Medicaid expansion. Still, several went out of their way in statements released after the ruling to cast Medicaid as a budget-buster in the law.

"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," Gov. Mitch Daniels of Indiana said. Indiana is seeking a federal waiver to cover more people through a program called the Healthy Indiana Plan instead.

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