By N.C. Aizenman and Karen Tumulty for the Washington Post

While the resistance of Republican governors has dominated the debate over the health-care law in the wake of 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 Medicaid programs, the chief means by which the law would extend coverage to millions of Americans with incomes below or near the poverty line.

“Unlike the federal government, Montana can’t just print money,” Gov. Brian Schweitzer (D) said in a statement Wednesday. “We have a budget surplus, and we’re going to keep it that way.”

The law would add an estimated 84,000 people to Montana’s Medicaid program, doubling its size, the governor said. Although the federal government would pay the vast majority of the additional costs, Montana’s health and human services department estimates the state’s share would reach $71 million in 2019. Outside groups say the costs would be far lower than that.

The range of state leaders expressing unease suggests that implementing the law could be rough going, with divisions not always breaking along party lines. The topic is likely to factor prominently in this week’s meeting of the National Governors Association in Williamsburg, Va. And it has been fueled by a long list of unanswered questions about the choice now before states.

In particular, it is unclear how the court’s pronouncement that states cannot be penalized for refusing to adopt the law’s more generous eligibility standards for Medicaid in 2014 changes the rules governing the expansion.

Will states that opt in have the option of scaling back in future years? If a state that opts out decides it wants to participate at some later point, will the federal government still pay nearly the full cost of covering those who become newly eligible for Medicaid? And can a state participate only partially — for instance, by raising the income cutoff for its program to a level lower than the ceiling envisioned in the law, which is set at 133 percent of the federal poverty line?

Asked at a forum Wednesday to describe state reactions to the Supreme Court ruling, Dan Crippen, executive director of the National Governors Association, offered a one word reply: “confusion.”

The association was one of several — along with the Republican Governors Association and the National Association of Medicaid Directors (NAMD) — to send a letter to Secretary of Health and Human Services Kathleen Sebelius this week with a voluminous list of queries.

“The answers to these questions are key,” said NAMD Director Matt Salo. “States need to be making these decisions now, and it’s hard to make them if you don’t have clarity.”

Continue reading…