The promise of free money is hard to turn down, and so when Obamacare offered the states a cheap way of expanding Medicaid, Gov. Rick Snyder found it hard to resist. Yet just a year into Michigan’s expansion, it’s not such a bargain.

In its mission to make sure more Americans have health insurance, the Affordable Care Act depended on states to expand their Medicaid programs to individuals with incomes under 138 percent of the federal poverty level.

Two reports released in the past week demonstrate a potential bifurcation in state insurance exchanges: The insurance marketplaces appear to be attracting a disproportionate share of low-income individuals who qualify for generous federal subsidies, while middle- and higher-income filers have generally eschewed the exchanges.

On Wednesday, the consulting firm Avalere Health released an analysis of exchange enrollment. As of the end of the 2015 open-enrollment season, Avalere found the exchanges had enrolled 76% of eligible individuals with incomes between 100% and 150% of the federal poverty level—between $24,250 and $36,375 for a family of four. But for all income categories above 150% of poverty, exchanges have enrolled fewer than half of eligible individuals—and those percentages decline further as income rises. For instance, only 16% of individuals with incomes between three and four times poverty have enrolled in exchanges, and among those with incomes above four times poverty—who aren’t eligible for insurance subsidies—only 2% signed up.

The Avalere results closely mirror other data analyzed by the Government Accountability Office in a study released last Monday. GAO noted that three prior surveys covering 2014 enrollment—from Gallup, the Commonwealth Fund, and the Urban Institute—found statistically insignificant differences in the uninsured rate among those with incomes above four times poverty, a group that doesn’t qualify for the new insurance subsidies.

WASHINGTON — House Republicans on Tuesday will unveil a proposed budget for 2016 that partly privatizes Medicare, turns Medicaid into block grants to the states, repeals the Affordable Care Act and reaches balance in 10 years, challenging Republicans in Congress to make good on their promises to deeply cut federal spending.

The House proposal leans heavily on the policy prescriptions that Representative Paul D. Ryan of Wisconsin outlined when he was budget chairman, according to senior House Republican aides and members of Congress who were not authorized to speak in advance of the official release.

With the Senate now also in Republican hands, this year’s proposal is more politically salient than in years past, especially for Republican senators facing re-election in Democratic or swing states like Pennsylvania, Wisconsin, Illinois and New Hampshire, and for potential Republican presidential candidates.

By our count at the Galen Institute, more than 49 significant changes already have been made to the Patient Protection and Affordable Care Act: at least 30 that President Obama has made unilaterally, 17 that Congress has passed and the president has signed, and 2 by the Supreme Court.

Indiana Governor Mike Pence has won approval from the Obama administration for a Medicaid waiver that begins the transformation of the program toward a consumer-directed model.

Gov. Pence is building on the popular and successful Healthy Indiana Plan (HIP) created by former Governor Mitch Daniels in 2007.

Both of them pushed the envelope with Health and Human Services officials who were determined to perpetuate a hide-bound program that is ill-serving tens of millions of recipients while gobbling up state revenues. Gov. Pence and his staff worked directly with White House officials to overcome this inertia and set down some new markers for future reform.

Gov. Pence announced today that the administration has approved Healthy Indiana 2.0 that will require contributions from all able-bodied Hoosiers participating in the program. It also creates an Employer Benefit Link that provides a Medicaid contribution for recipients who are eligible and participating in employer-sponsored health insurance plans. In addition, recipients who do not make their required contributions toward their health benefits can be locked out of the program for six months. All recipients will be required to make a contribution toward their Medicaid benefits, even those who are at the lowest income eligibility levels.

While conservatives are sure to criticize this plan as an expansion of Medicaid, I see it as taking advantage of an opportunity to lay the groundwork for the kind of Medicaid reform that we must move toward in the future. It would not be possible to rip out this program root and branch and replace it with a consumer directed model. By winning approval of these changes through a Medicaid waiver, other governors have a much stronger platform to move toward other changes that will work for their states.

HIP creates a POWER Account that is jointly funded on a sliding scale by the recipient and the state. Recipients at 138% of poverty must contribute $54.86 a month for a family of four to participate, for example. Families at 100% of poverty have to contribute $39.75 a month. If they do not make their contribution, they face the lock out.

The $2,500 POWER Account gives people an incentive to monitor their spending for their routine medical expenses. There also are penalties for unnecessary visits to emergency rooms.

Absent Obamacare, many conservatives would praise this effort to make Medicaid look more like a Health Savings Account and catastrophic high-deductible coverage. This is an important start toward much-needed changes to this public program. By using the ObamaCare waiver option that the administration wanted, Gov. Pence has gained important and potentially transformative changes to Medicaid. This is a win.

Key Points
•Avik Roy’s Transcending Obamacare reform proposal retains a number of core features of the Affordable Care Act, even while promising to modify them at the margins.
•Despite the plan’s initial aversion to political risk, Roy places several longshot bets on proposed policy reform results.
•The plan strives too narrowly to ensure that high-deductible health insurance will be the dominant (or, perhaps, exclusive) form of exchange-based coverage and neglects or avoids a number of other reform opportunities. It is also prone to overly optimistic fiscal projections, insufficient details, and ad hoc revisions that fail to hold together.

WASHINGTON, D.C. — Healthcare costs and lack of money or low wages rank as the most important financial problems facing American families, each mentioned by 14% of U.S. adults. Fewer Americans than a year ago cite the high cost of living or unemployment, and the percentage naming oil or gas prices is down from 2012.

Gallup has been asking Americans about the most important financial problem facing their family in an open-ended format for the past 10 years. Healthcare this year has returned to the top of the list for the first time since early 2010, when the Affordable Care Act, or “Obamacare,” was signed into law. Still, Americans viewed it as an even bigger financial problem in 2007, when a range of 16% to 19% said it was most important.

Earlier this month The Foundation for Government Accountability conducted a poll of 500 voters from the November 4th, 2014 general election in the State of Tennessee and found that when they know the facts about expansion, they do not support it in the Volunteer State.

When respondents were told that proposed Medicaid expansion is paid for with $716 billion in cuts to seniors on Medicare, nearly 80 percent of poll respondents were less likely to support Medicaid expansion.

By Avik Roy On March 4, the Supreme Court will hear oral arguments in King v. Burwell, the case that many pundits claim will “blow up Obamacare.” That’s an exaggeration; whatever the High Court decides, Obamacare will remain entrenched in federal law. But if the Supremes do end up ruling against the Obama administration—a distinct possibility—they will be giving Congress a uniquely important opportunity to reshape the Affordable Care Act in far-reaching ways. Here’s how that could work.

New York Times correspondent Abby Goodnough asks if the latest legal challenges to ObamaCare are signaling a divide within the party or are Republicans still recovering from getting burned when the ACA went to the Supreme Court last time?”
About 5 million middle-income people in 36 states currently are receiving subsidies for health insurance through the federal exchanges. Since 87 percent of them are receiving subsidies to purchase coverage, many likely would no longer be able to afford coverage.
Ms. Goodenough reports that after the health overhaul law was passed in 2010, Republicans on both the state and federal level spoke with one voice flatly rejecting ObamaCare. However, in the years following ObamaCare’s passage while the majority of governor’s still remain critical of the law, nine governors have expanded their Medicaid programs and four more governors are considering Medicaid expansion this year at the urging of hospitals and business groups.
In the past months, a number of conservative groups and political leaders have filed Amicus briefs in the King vs. Burwell challenge that will be heard by the Supreme Court on March 4. As a result, Ms. Goodenough reports that new attention is being drawn to the divisions within the Republican Party over the law. . Almost two dozen briefs were filed on behalf of the plaintiffs in the King case, but she says “shockingly few state officials” signed on.
One of the few exceptions was the Amicus brief filed by the Galen Institute which had 19 Republican state legislators in Tennessee and two in Ohio join. Other notable briefs include one filed by six Republican state attorneys general- in Alabama, Georgia, Nebraska, Oklahoma, South Carolina and West Virginia. Divides in the party can be seen within states like Florida where Senator Marco Rubio who signed a brief with 14 members of Congress, but Florida’s Republican Attorney General, Pam Bondi, did not join in the States brief.