Because the premium tax credit schedule for health insurance exchanges begins at 100%, Florida's decision not to expand its Medicaid program will leave an estimated 995,000 eligibles, whose incomes are less than 100% FPL, with no access to either tax credits or subsidies.
Nationally 11.5 million adults will find themselves in the same boat because their income is less than 100% of the FPL.
Reuben's group will also keep a close eye on efforts by the Centers for Medicare & Medicaid Services to encourage states to increase Medicaid coverage. "What kind of give and take is there between the federal government and state governments that would make it more interesting for states to expand Medicaid coverage?"
He points to Florida's Medicaid program, which currently operates under a CMS waiver. The state has asked CMS for a waiver to treat all Medicaid recipients under a managed care program. "That's an opportunity for some give and take."
DSH payments may present another opportunity for give and take. Disproportionate share hospital programs for facilities that treat a large number of indigent patients are embedded in the ACA, which provides the Department of Health and Human Services with the discretion to allocate the cuts.