In a report, the Department of Health and Human Services said Monday that there are around two million low-income, uninsured people in those 20 states who have a mental illness or substance abuse disorder.

Medicaid has long been a joint federal-state program that offers near-free care to the very poor. Under the health law, Washington pays almost all of the costs of insuring people who have slightly higher incomes.

Opponents of expansion argue that neither states nor the federal government can afford to further swell the program, and that a shortage of providers to treat the newly insured poses an additional challenge in trying to enroll more people in it.

Many have blamed the increase on the Affordable Care Act, which expanded health insurance coverage to millions more Americans through Medicaid — known as Medi-Cal in California — and government-run health exchanges.

Last year, a national survey of 2,099 emergency doctors by the American College of Emergency Physicians reported that 28 percent of respondents said the volume of ER patients in their hospitals “increased greatly” since the health law took effect. And 47 percent said the volume “increased slightly.”

Vermont has filed a 1332 state innovation waiver to avoid building a website for its small-business insurance exchange. The state hopes to have those employers enroll directly through insurers.

Under the waiver, beginning Jan. 1, 2017, states can request that the federal government waive basically every major coverage component of the Affordable Care Act, including exchanges, benefit packages, and the individual and employer mandates. The only requirement is that a state’s healthcare coverage remains consistent and adequate. Vermont is the first state to send a finalized request (PDF) to the CMS.

The co-ops represent a modest component of the sweeping 2010 health law that put new coverage requirements on insurers and required most Americans to have health insurance or pay a penalty. The co-ops were included to foster nonprofit health insurance providers to compete in the individual and small group markets.

The report will be released in advance of a Senate Finance Committee hearing on Thursday. It is likely to spur more questions about prospects of the Obama administration’s $2.4 billion co-op program.

Thousands of doctors, hospitals and providers in some states still haven’t been paid for health services given to members insured by the co-ops. More than half a million people signed up for health insurance under the ACA lost coverage or had to get new insurance because their co–op had folded.

The central feature of the latest plan in Nebraska is to deliver Medicaid expansion benefits through health plans sold on the Obamacare exchange, instead of through the state’s managed care system. But, at the end of the day, this is really just a more expensive way to expand Medicaid under Obamacare.

Nebraska’s own actuaries estimate that using these plans to expand Medicaid would increase per-person costs by 94% next fiscal year. By 2021, the cost difference is expected to reach 150%. Overall, this plan would cost taxpayers billions of dollars more (as if regular Medicaid expansion wasn’t expensive enough) and leave even fewer dollars for the truly needy.

Six of the 32 states implementing the Affordable Care Act’s Medicaid expansion to date have done so through Section 1115 waivers. Using these waivers, the Centers for Medicare and Medicaid Services has approved terms that extend beyond the flexibility provided by federal law. Section 1115 waivers authorize research and demonstration projects that, in the view of the Health and Human Services Secretary, further the purposes of the Medicaid program. The ACA implemented new requirements for these waivers, including that states must have a publicly available, approved evaluation strategy. States also must submit an annual report to HHS that describes the changes occurring under the waiver and their impact on access, quality, and outcomes.

State Medicaid agencies say Congress’ decision to suspend the Affordable Care Act’s tax on health insurers for one year is a good first step, but they are pushing for its permanent repeal.

While most private health insurance plans have had to pay the tax themselves, states that contract with Medicaid managed-care plans have had to cover the premium tax to ensure that the health plans receive actuarially sound rates. Thirty-eight states and the District of Columbia contract with Medicaid managed-care plans.

Donald Trump had a complete meltdown Thursday night when he got locked in this exchange with Marco Rubio over health care. Rubio kept pressing him on what his plan for health care was, and Trump responded by incoherently talking about getting rid of “the lines around the states.” Essentially, Trump wants to increase competition by allowing insurers to sell plans across state lines without regard to the states’s own insurance regulations.

Setting aside the fact that Trump’s understanding of health care policy is woefully inadequate, his one idea on health care isn’t even a good one. Granted, this is an idea a lot of Republicans have floated and, in theory, increased insurance competition is needed and state insurance regulations are often an impediment to this. But in practice, the idea runs into the buzzsaw of federalism.

Six states filed a new lawsuit Wednesday against the Obama administration over the Affordable Care Act.

The complaint that Texas, Wisconsin, Kansas, Louisiana, Indiana and Nebraska filed in the Northern District of Texas takes issue with the Health Insurance Providers Fee assessed to health insurers to cover federal subsidies.

The lawsuit says nothing in the Affordable Care Act’s language provided clear notice that states would also have to pay the fee.

“This notice was not even provided by rule but was ultimately provided by a private entity wielding legislative authority,” the suit says.

Health Republic Insurance Company of Oregon, a Lake Oswego-based insurer that is phasing down its operations, on Wednesday filed a $5 billion class action lawsuit on behalf of insurers it says were shorted by the federal government under an ObamaCare program.

The lawsuit, filed in the United States Court of Federal Claims, focuses on a program that was intended to offset insurer losses in the early years of the implementation of the Patient Protection and Affordable Care Act.

Instead, payments to insurers under the “risk corridor” program amounted to 12.6 percent of the amount expected for 2014, and are expected to be similarly low for 2015.

Federal law and regulations “are unequivocal about the payments the Government must make,” according to the lawsuit. “The law is clear: the Government must abide by its statutory obligations.”