Governors in five states say they oppose expanding theirMedicaid programs under President Barack Obama's health-careoverhaul, and another 26 haven't decided, an option created by aU.S. Supreme Court ruling that may prevent millions of low-incomeAmericans from obtaining insurance.

Governors of Florida, Louisiana, Iowa, South Carolina andMississippi object, saying they're concerned rising health-carecosts may force tax increases or cuts to services, even as thefederal government is promising to cover all the added Medicaidcosts in the first three years and 90 percent after that. Thefederal reimbursement is about 59 percent now, on average.

Most of the governors resisting the Medicaid expansion areRepublicans who objected to the health-care law as unconstitutionalor too costly. If all 31 states don't go along, as many as 11.4million Americans who would otherwise be eligible for expandedMedicaid may be left without the coverage that Obama and Congressintended to offer, according to the Urban Institute, aWashington-based research group.

Without Medicaid, states are unlikely to have the resources tofill the gap, said Genevieve Kenney, a researcher at theinstitute.

“I don't see a way for these folks to get coverage,” Kenneysaid.

A U.S. Supreme Court ruling on June 28 upheld the heart ofObama's health-care law, requiring most people to obtain insuranceor pay a fine, an idea originally embraced by Republicans. Thejustices also ruled that the federal government can't threaten towithhold existing Medicaid money from states that don't fullycomply, as the law said, allowing states to opt out.

Obama's health-care law, called the Patient Protection andAffordable Care Act, was designed to open the state-run program toan estimated 17 million low-income Americans by admitting peopleearning as much as 133 percent of the federal poverty level, orabout $30,657 for a family of four this year.

The five Republican governors said they are opposed to theexpansion in public statements or in interviews with theirspokesmen.

Governors in at least 26 states — 23 Republicans and threeDemocrats — said they're reviewing the decision or are waiting forthe outcome of the November presidential election because MittRomney, the presumptive Republican nominee, has called forrepealing the health law.

Democratic Governors

The three Democrats are Jay Nixon in Missouri, John Hickenlooperin Colorado and Earl Ray Tomblin in West Virginia. Republicangovernors include Rick Perry of Texas and Scott Walker ofWisconsin.

Indiana Governor Mitch Daniels, who leaves office in January,said the next governor and Legislature will need to decide how toproceed.

Florida Governor Rick Scott said July 1 that implementation ofthe Medicaid expansion alone would cost the state about $1.9billion. Scott said in a statement that “the burden increasinglyshifts to Florida taxpayers.”

From 2014 to 2019, Florida would have to pay $1.23 billion instate money and would receive $20.1 billion in federal funds,according to the Kaiser Family Foundation, a health-research groupin Menlo Park, California.

Bobby Jindal of Louisiana said he isn't implementing thehealth-care law and wants Romney to defeat Obama and help undo themeasure. Mississippi Governor Phil Bryant doesn't plan to expandMedicaid even if Obama wins, said Mick Bullock, a spokesman, in ane-mail.

While Republican Governor Terry Branstad of Iowa hasn't made anannouncement, it's “highly unlikely” the state will expand Medicaidbecause the governor doesn't trust the federal government to keepits promises, said Tim Albrecht, a spokesman.

Iowa will be able to provide coverage to “a significant number”of 150,000 uninsured residents with state health-care initiatives,Albrecht said.

Republican Governor Dave Heineman of Nebraska also said in aJune 28 statement that he would oppose efforts to raise taxes orcut education funding to pay for a Medicaid expansion.

Governor Chris Christie, a New Jersey Republican, said previousDemocratic governors expanded Medicaid about as far as the statecan afford.

“We're taking a hard look at it,” Christie said July 3 on FoxBusiness Network. “I doubt that we could expand Medicaid in NewJersey a whole lot more.”

Rejecting Expansion

Governors will have difficulty rejecting Medicaid expansion asthey face pressure from constituents, said I. Glenn Cohen, aprofessor at Harvard Law School in Cambridge, Massachusetts, whospecializes in health issues.

“It's a very hard thing for a governor, as a matter ofprinciple, to turn down funding and basically keep a number of hisconstituents who are poor basically without health care,” Cohensaid in a telephone interview.

Even if a governor supports the expansion, legislatures couldstill decline to authorize the funding, said Ray Scheppach, theformer executive director of the National Governors Association whois now a professor of public policy at the University of Virginiain Charlottesville.

“The state fiscal situation continues to be pretty bad, and thisis going to make it worse,” Scheppach said.

States' decisions will affect providers.

Hospitals, especially those that treat many poor people, havewarned that failing to expand Medicaid could put them in financialjeopardy. Managed-care companies that focus on Medicaid, includingVirginia Beach, Virginia-based Amerigroup Corp. and Saint Louis,Missouri-based Centene Corp., won't see as many customers as theyhad expected if governors opt out of the expansion.

The Medicaid expansion would cost states $21 billion through2019, according to Kaiser. The federal government would contribute$444 billion, the group said in the report.

States whose Medicaid programs now have the lowest eligibilitystandards stand to gain the most.

Texas, for example, where working-age adults with children areineligible for Medicaid if they make more than a quarter of thepoverty level — and childless adults aren't eligible at all — wouldbe turning down $52.5 billion from 2014 to 2019, or 20 times theamount it would spend on the expansion itself, according toKaiser.

Perry, the Texas governor, on June 28 called the Supreme Courtdecision “a stomach punch to the American economy,” and said hewould consult with state officials.

U.S. Contribution

Congress may reduce the federal government's contribution, saidDean Clancy, legislative counsel and vice president for healthpolicy at FreedomWorks, a Washington nonprofit that supports TeaParty groups.

“It's a trap,” Clancy said. “It's free money today that won't befree tomorrow.”

States should instead lobby Congress to convert their Medicaidfunding into a “block grant,” which would give greater flexibility,he said. Governors would have more freedom to run the program, andcould stop covering some services or use the money to subsidizeprivate health insurance for the poor, Clancy said.

Georgia Governor Nathan Deal said it may be in Georgians' bestinterests to participate in the expansion despite his personalopposition. The Republican has said he's concerned that Georgians,as federal taxpayers, will be paying for expansions in other stateseven if the state opts out.

“That's certainly a question we would have to ask, if that'sprudent,” he said at a June 28 news conference at the stateCapitol.

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