In Pennsylvania, more than a half-million people who don't have insurance are waiting to hear whether the state will take advantage of a Medicaid expansion that's part of the Affordable Care Act.
The federal law would allow people earning up to 138 percent of federal poverty guidelines to sign up for Medicaid. But a Supreme Court ruling that largely upheld the law gave states the choice whether to expand their Medicaid programs.
About half decided against it or are still working out agreements with the Obama administration. Pennsylvania falls into that latter category, leaving the state's working poor in limbo for now.
Substitute teacher Susan Mull says she has lived without insurance for 13 years. At age 60 that would be stressful enough, but Mull also is HIV-positive. She was diagnosed 21 years ago.
"I never thought that I would become a grandmother," says Mull. "We were told in the early 1990s that we simply wouldn't live long."
Because of how little Mull and her husband earn, they could qualify for Medicaid under an expansion. The annual income limit for a couple is $21,404.
Mull says she's never been sick and receives low-cost care and free HIV medication through government programs. But she says full health care coverage — including checkups, eye exams and dental visits — would bring a level of security she hasn't known for a long time.
"I'll be able to embrace that whole part of the system that I have been away from for 13 years," says Mull.
While Republican governors in neighboring New Jersey and Ohio have agreed to expand Medicaid, Pennsylvania Gov. Tom Corbett hasn't yet.
Earlier this month he proposed the Healthy PA plan, which includes a Medicaid overhaul. It still taps into the billions of dollars in federal Medicaid expansion money available to states, but it also asks the federal government to approve significant changes in how the program is run.
Part of the proposal is similar to those in Arkansas and Iowa. New enrollees would get coverage from private health insurance companies through health exchanges. Corbett also wants new beneficiaries to look for work and pay a premium of up to $25 a month.
"It's a Pennsylvania-based plan that is based on common-sense reforms, creates real health care choices, reduces government bureaucracy and provides a pathway to independence for all Pennsylvanians," said Corbett in announcing his proposal.
The U.S. Department of Health and Human Services says it needs more detailed information before approving the proposal. "HHS is committed to supporting state flexibility and working with states to design Medicaid programs that work for them, within the confines of the law," says agency spokesman Fabien Levy.
Advocates for expanding the Medicaid program in Pennsylvania say they're encouraged the governor has proposed something. But they'd prefer a plan that doesn't place new burdens on beneficiaries.
"The work requirement provision we, obviously, have concerns about — we don't want to see more barriers created for folks to access care," says Antoinette Kraus, director of the Pennsylvania Health Access Network.
Insurance companies and the health care industry are pleased Corbett wants to pursue federal funds to expand Medicaid. "The more people that walk through the doors of hospitals — who are insured — the better off our hospitals are," says Curt Schroder, regional executive of the Delaware Valley Healthcare Council. Still, Schroder says, there are many details to work out.
That means those who could benefit from a Medicaid expansion, like Susan Mull, will have to wait. While some states begin signing up Medicaid beneficiaries on Oct. 1, it could be months before that happens in Pennsylvania.
STEVE INSKEEP, HOST:
OK, a government shutdown would be unlikely to affect the rollout of ObamaCare. As the law currently stands, people will be able to enroll in state and federally run health exchanges starting October 1. Even after that enrollment starts, though, the fight over the details of ObamaCare will continue, because the law also expands Medicaid, the health program largely focused on the poorest and most vulnerable.
DAVID GREENE, HOST:
Last year, the Supreme Court gave states the choice of whether or not to participate in an expansion of that program. About half decided against it. States including Pennsylvania are still working out agreements with the Obama administration, and that leaves the state's working poor in limbo. NPR's Jeff Brady has the story.
JEFF BRADY, BYLINE: We're in rural Lancaster County in a buzzing garden that belongs to substitute school teacher Susan Mull.
SUSAN MULL: I've now been totally without insurance for 13 years.
BRADY: Because of how little Mull and her husband earn, they may qualify for an expanded Medicaid program. The annual income limit for a couple is just over $21,400. At 60 years old, not having insurance is stressful enough, but there's more. Mull also is HIV-positive. She was diagnosed 21 years ago.
MULL: I never thought that I would become a grandmother. We were told in 19 - early 1990s that we simply wouldn't live long.
BRADY: Mull says she's never been sick and receives low-cost care and free HIV medication through government programs. But she says full health care coverage, checkups, eye exams and dental visits, that would bring a level of security she hasn't known for a long time.
MULL: I'll be able to embrace that whole part of the system that I have been away from for 13 years. And I'm smiling. You can't see that on the radio.
BRADY: Mull lives among more than a half million Pennsylvanians waiting to learn if the state will expand its Medicaid program. Antoinette Kraus with the Pennsylvania Health Access Network points out that even as neighboring states with Republican governors embraced Medicaid expansion, Governor Tom Corbett did not.
ANTOINETTE KRAUS: Pennsylvania's really been this kind of island of no. We've seen Governor Christie come out and support Medicaid expansion. We've seen Governor Kasich of Ohio support Medicaid expansion. So Pennsylvania's really just been stuck in the middle, not moving forward until this point.
BRADY: Earlier this month, Governor Corbett proposed a Medicaid reform plan. It would tap into the billions of dollars in federal Medicaid expansion money available to states, but it also asks the federal government to approve significant changes in how the program is run. Corbett toured medical facilities last week to promote his plan.
GOVERNOR TOM CORBETT: I get a little nervous being around all these doctors, but I am healthy.
BRADY: Part of the Corbett's Medicaid overhaul is similar to proposals in Arkansas and Iowa. New enrollees would get coverage from private health insurance companies, but Corbett also wants new beneficiaries to look for work and pay a sliding scale premium up to $25 a month.
CORBETT: It's part of the request that I put together that was sent to the Department of Health and Human Services in Washington, and I think we've gotten their attention with this program.
BRADY: A spokesman for HHS says the agency wants to work with Pennsylvania but needs more details about how the plan would work. Insurance companies and the healthcare industry are pleased Governor Corbett wants to pursue Medicaid expansion money. Curt Schroder is with the Delaware Valley Healthcare Council.
CURT SCHRODER: The more people that walk through the doors of hospitals who are insured, you know, the better off our hospitals are.
BRADY: But there are questions about whether the Obama administration will approve the changes to Medicaid that Governor Corbett wants. Matt Salo heads the National Association of Medicaid Directors. He says requiring beneficiaries to look for a job may not be legal, but even if it is...
MATT SALO: I think it's probably an uphill battle for Pennsylvania, for the administration to approve this, because they're not currently inclined to - honestly to put any kind of preconditions on healthcare coverage like this.
BRADY: As policymakers work out the details, those who could benefit from a Medicaid expansion in Pennsylvania will have to wait. While some states begin signing up new beneficiaries in a few days, it could be months before the program is in place here. Jeff Brady, NPR News, Philadelphia. Transcript provided by NPR, Copyright NPR.