04/26/2013 12:57 pm ET Updated Jun 26, 2013

What Are the Options When States Reject Medicaid Expansion for the Working Poor?

In states that continue to reject the Affordable Care Act (ACA or "Obamacare") or more importantly the Medicaid expansion, there is a critical question that must be answered - will the working poor remain uninsured? Currently, there are twenty-six states that continue to reject creating health exchanges and thirty states who refuse to expand their Medicaid programs. Surely the President, Congress, state governors and state legislators will not just stand by, but will find acceptable alternatives. Unfortunately, the GOP's posture seems to be one of non-engagement in hopes that the President's signature legislation will fail. Just take a look at the posturing done just this week in the House of Representatives when GOP leaders could not come up with the votes for a health care bill written by their own party.

Most health professionals, policy analysts, and politicians agree that health care costs are out of control. One can argue that the quality of care provided fails to match with the cost of care. So, the 2009 focus on health care reform was arguably a reasonable answer to this critical imbalance. The purpose of health care reform vis-à-vis the Affordable Care Act was a noble vision, to provide health insurance for all Americans, including the working poor and the very poor who are not yet covered by Medicaid. This includes those living below 138 percent of the federal poverty level or more precisely covers those earning up to $32,599 a year for a family of four. At the time ACA was enacted, it was estimated that this group represented 22.3 million uninsured persons.

The states' health care exchange component is an integral part of the law that sets up the marketplace for citizens to choose the insurance that's best for them. In other words, the exchanges hold together the infrastructure and mechanisms for distributing care within states. The state exchanges, together with the other most controversial part of ACA, Medicaid expansion, are the two aspects that would cover the working poor.

When the Supreme Court ruled that the Affordable Care Act was constitutional, the High Court also ruled that the federal mandate for Medicaid expansion was unconstitutional. The ruling therefore gave states the option to voluntarily expand their Medicaid program for more Americans to gain access to health care. As designed by Congress, the expansion was thought to be attractive to the states because the federal government committed to fund 100 percent of the expansion for the first three years. Thereafter, the federal government will pay 90 percent and the states' cost sharing would be 10 percent. Yet, only twenty states and the District of Columbia have opted to expand their state's Medicaid programs.

The reelection of President Obama has set into motion the implementation process that will require all stakeholders to work together. As a result, several of the Governors who were once opposed to the law are now considering their political future and the political consequences of leaving millions of people without access to health care. Over the past few months, we have seen movement by elected officials and other thought leaders to begin publicly embracing the Medicaid expansion. For instance, Republican Governors Rick Scott, Jan Brewer, Chris Christie, and John Kasich have all voiced support to expand their states' Medicaid programs. Despite the opportunities, the path forward is wrought with potential pitfalls at nearly every level of government. For instance, the state executives who have expressed support to expand Medicaid are being met with political resistance within their own party.

Many of the states that have decided not to expand Medicaid have high numbers of uninsured persons- take for example Texas that has an estimated 1.8 million people who will be left behind without the expansion. For Americans without health insurance coverage - what options will they have? Fundamentally, I believe the American people deserve a responsive government. Elected officials at the state level must work together to find a solution that works for their constituents. It's encouraging to see that several states are considering their own initiatives by expanding Medicaid through private insurance - solutions like these are worth the debate and dialogue. Further, the Department of Health and Human Services is encouraging eligible organizations to partner with the Federal government to operate state exchanges. Simply put, we must commit to do more to help the working poor. Providing affordable health care is too important to the welfare, health, and our economic well-being not to find a solution.