Along with Washington D.C., 23 states are expanding Medicaid eligibility under the Affordable Care Act, while 21 are currently on the record declining expansion and six are kind of on the fence.
The legislature in one of the undecided states, Michigan, is holding a special session to vote on the issue, which has large ramifications for the people of Detroit and its healthcare economy. Republican Governor Rick Snyder has been calling for Medicaid expansion -- the state has almost 13 percent uninsured rate -- and is also proposing the idea of subsidizing Detroit city government retirees in the state-federal partnership insurance marketplace.
Detroit's emergency city manager has proposed the HIX-for-retirees plan as a way to stem the tide of its fiscal crisis, and Snyder has promoted the idea, but it has failed to garner legislative support. The Medicaid expansion vote is likely to be even more tenuous.
Whatever the fate of expansion in Michigan, in Indiana, and in Ohio, Montana, Tennessee and Utah, state legislatures are not likely going to opt out, according to an Avalere Health analysis.
That's likely to sow some confusion for consumers in those states, since insurance marketplaces are also designed to be gateways for Medicaid applications. People who happen to fall into certain income brackets below 138 percent of the federal poverty level may face a coverage gap, and they'll also be exempted from the individual mandate penalties.
In Indiana, state health officials are waiting for word from the feds on a Medicaid waiver application that would continue the Healthy Indiana Plan, an alternative Medicaid program that offers some low-income and working adults subsidized insurance with an HSA and some cost-sharing.
As new federal insurance and Medicaid rules take effect separate from the decision to expand eligibility, Republican Governor Mike Pence's Administration is asking the Centers for Medicare & Medicaid Services to let the state continue the program for the roughly 40,000 current enrollees.
(Indianapolis, the state's capital and largest city.)
The Healthy Indiana Plan has entered into the expansion debate, as various healthcare groups and policy advocates call on the Governor and legislature to hold a vote.
"If Indiana leaders agreed to expand Medicaid, only 8 percent of the state's non-elderly population would be without healthcare coverage, compared with the 17 percent who now go without," the Fort Wayne Journal Gazette wrote in an editorial titled "ObamaCare offers affordable choice."
Pence, meanwhile, has made a point of promoting the Healthy Indiana Plan in his weekly media addresses, while predicting problems with the ACA.
In Ohio, a coalition of healthcare providers and advocacy groups are trying to pressure the legislature and governor to expand eligibility -- and Republican Governor John Kasich has proposed an expansion plan, which would see coverage extended to more than 250,000 Ohioans. The legislature has yet to vote, and one Republican representative from the eastern Cincinnati suburbs is making news for introducing legislation to pare back Medicaid eligibility.
In Montana, too, there is pressure on Democratic Gov. Steve Bullock to corral the legislature together for a special session via executive order to consider Medicaid expansion in legislation.
In Utah, the governor recently announced that he will put off a decision about Medicaid until next year. Lawmakers in other states, including in-limbo Tennessee, and Alaska and Wyoming, which are not expanding eligibility, are considering legislation that would create an insurance exchange for some, or most, Medicaid beneficiaries, following the "private option" model being pioneered by Arkansas.