“The Congressional Budget Office (CBO) has just published, in two reports, its updated score of the 2010 health care law. The new score is bad news from almost any vantage point. CBO’s fiscal evaluation of the law is worse than before, even though the number of people receiving health insurance coverage is now projected to be fewer.”

“But as they gathered here this weekend at a meeting of the National Governors Association, most governors in both parties said that faced with a choice they did not expect to have, they needed to study how to proceed with this significant change in federal-state relations. Not all Democrats were leaping at the chance to expand their programs, and not all Republicans were ruling it out.”

“While the resistance of Republican governors has dominated the debate over the health-care law following last month’s Supreme Court decision to uphold it, a number of Democratic governors are also quietly voicing concerns about a key provision to expand coverage. At least seven Democratic governors have been noncommittal about their willingness to go along with expanding their states’ Medicaid programs, the chief means by which the law would extend coverage to millions of Americans with incomes below or near the poverty line.”

“Setting aside the brazen intrusion into state sovereignty and the gross federal overreach, the practical problem with ObamaCare’s Medicaid expansion is that the product the administration is selling is broken. State and federal budgets are simply unable to handle an expansion of this magnitude.”

“So, by refusing to go along with Obamacare’s Medicaid expansion and by blocking state-run exchanges, governors are not just saving state taxpayers money. They are potentially reducing future federal spending by as much as $1.5 trillion over the next ten years. While congressional Republicans have been reduced to taking symbolic repeal votes, and Mitt Romney struggles to determine whether or not the individual mandate is a tax, governors — and state legislators — have become the real heroes of the fight against Obamacare.”

“Much attention has been given to the argument that without the individual purchase mandate, other parts of the health care law would become unworkable. Much less attention has been given to the fact that without the states forced to be on board with the Medicaid expansion, the law’s health exchange subsidies might be fiscally unworkable. The Supreme Court may have just set in motion of chain of events that could lead to the law’s being found as busting the budget, even under the highly favorable scoring methods used last time.”

“The Roberts court declared this threat unconstitutional, finding that Washington could use the carrot (dangling new money) but not the stick (withdrawing old money). The states, when they initially signed up for Medicaid, could not have anticipated that Congress would one day enact a law that caused Medicaid to be ‘no longer a program to care for the neediest among us, but rather an element of a comprehensive national plan to provide universal health insurance coverage,’ the Court reasoned.”

“For states, this is a clear winner – covering more individuals and saving budget dollars at the same time. For the taxpayer this is a nightmare. The taxpayer would save some money on the Medicaid expansions that would not take place (where the feds pay 90 percent of the cost) but they will pick up the full cost of the additional and generous insurance, bearing an additional $500 billion over ten years.”

“Medical specialists are urging regulators to slow implementation of an initiative funded by the 2010 healthcare law that aims to streamline care for some low-income elderly and disabled patients. “

“The health reform law changes that: It raises Medicaid rates for primary care to match those of Medicare for 2013 and 2014. That, the Obama administration hopes, will lure doctors to accept Medicaid patients — and also prevent some costly emergency room visits down the line. But there’s a problem: The payment boost runs out at the end of 2014. While the federal government estimates that it will spend $11 billion raising provider rates for 2013 and 2014, no additional federal funds are appropriated beyond that. There’s already some thinking, among the health-care provider community, that a fierce lobbying battle could play out as doctors look to turn a short-term pay boost into a permanent one.”