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.
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