June 29--CHARLESTON, W.Va. -- The U.S. Supreme Court's health care ruling leaves state officials with a tough choice that could determine whether thousands of low-income West Virginians receive the health insurance they were promised.

While the court upheld the bulk of the health care law, it also ruled states could opt out of a federal plan meant to provide government-run insurance to 16 million low-income Americans.

The law was designed to force states to expand their Medicaid programs to insure anyone with income of up to 133 percent of the federal poverty level, which is about $30,000 for a family of four.

States technically have decided not to do that, but they would have lost all of their federal Medicaid funding. The health insurance program for the poor is jointly funded by state and federal government.

Medicaid currently insures about 420,000 West Virginians making up to about 30 percent of the federal poverty level.

Chief Justice John Roberts said the federal government had unconstitutionally put "a gun to the head" of states and their Medicaid programs. He struck down the provision that allowed the federal government to yank all funding.

Now, states can choose not to expand their Medicaid programs and face no penalty. But, if they do expand their programs, they soon will have to come up with millions of additional dollars to pay for the expansion.

Because of the ruling, West Virginia and states across the country now have to make a politically delicate and financially taxing decision.

Here, the choice is this: expand Medicaid to insure about 130,000 poor people starting in 2014 and come up with tens of millions of dollars to pay for it -- or leave tens of thousands of poor people uninsured.

The choice is easy at first. The federal government will pick up the entire tab in the first few years. But, after 2020, states have to pay 10 percent of the bill. That's a small portion, but it amounts to millions and millions of dollars depending on the state.

Rockefeller worried

U.S. Sen. Jay Rockefeller, D-W.Va., is deeply concerned states will choose not to expand their Medicaid programs. That would mean millions of poor Americans would be left behind by a law designed to help them most.

"It appears the ruling could have seriously undermined their health care options," Rockefeller said. "The decision still leaves in place an enormous financial incentive for states to do the right thing and expand coverage to this group. I hope every state will do that because these are good people who effectively have no other realistic option for affordable health care."

It's unclear what will happen in West Virginia.

"It's a choice I didn't know I had until a few hours ago, so, we need to gather the information to make an informed choice," said House Speaker Rick Thompson, D-Wayne.

State Delegate Don Perdue, chairman of the House Health and Human Resources Committee, said the state must go ahead with the expansion.

"You could opt out of it," the Wayne County Democrat said. "Is it the right thing to do? Absolutely not because it harms more citizens -- if you don't do it -- in a very profound way."

It is not clear what Gov. Earl Ray Tomblin's administration will do. He made only a tentative and vague comment about the law on Thursday. Three officials in his administration did not comment on questions about the Medicaid expansion.

Republican Bill Maloney, who is challenging Tomblin for governor, said Democrat Tomblin has no plan to pay for the expansion. While Maloney wants to see the whole health care law repealed, his campaign did not say specifically what he would do about the Medicaid expansion.

But it's not clear to what extent the issue will become politicized. That's because choosing not to expand Medicaid means West Virginians who thought they had been promised insurance could remain without it.

'Always been political'

Sam Hickman, the head of the state chapter of the National Association of Social Workers, said Medicaid had always been subject to politics.

"It's always been political, and coverage has always depended on who is in the executive branch and what their theories of health care are," Hickman, a supporter of the expansion, said.

Leaders of the Democrat-controlled Legislature want to study the issue, but they seemed to lean toward finding a way to expand Medicaid.

Senate President Jeff Kessler, D-Marshall, said the state needs to carefully consider the costs.

"But," Kessler said, "I'm convinced the health care of the people of the state is important enough that we need to encourage and enroll people for appropriate and available health care services, particularly those who can be enrolled at no or minimal costs to the state."

In the early years of the expansion, which starts as soon as 2014, the federal government says it will pick up 100 percent of the tab. By 2020, the state will pay 90 percent of the program's costs.

It's unclear how much the state will end up paying each year, though it's assuredly tens of millions of dollars. The Medicaid program is already threatening to destabilize the state budget, and the Tomblin administration is trying to figure out how to deal with a $200 millionMedicaid shortfall for the budget year that begins next summer.

In Ohio, Republican Gov. John Kasich said he feared what the Medicaid expansion would do to his state.

"We are very concerned that a sudden, dramatic increase in Medicaid spending could threaten Ohio's ability to pursue needed reforms in other areas, such as education," he said.

West Virginia Senate Finance Committee Chairman Roman Prezioso, D-Marion, said the state would have to find some way to pay for the Medicaid expansion as the federal match decreases.

"I'm going to have to look at its long-term costs that we're going to have to encumber dollars to pay for," he said.

U.S. Sen. Joe Manchin, D-W.Va., praised the court's decision on Medicaid because it "makes clear that states must have the flexibility to live within their means by determining Medicaid eligibility as each state sees fit."

When Manchin was still governor in 2009, he wrote a letter to Congress asking it to cover the entire cost of the Medicaid expansion forever instead of gradually moving some of the burden to the states themselves. Congress didn't listen, in part because the federal government has budget problems of its own.

Some hope the state will save money in the long run, even if the upfront costs appear steep. State Senate Health and Human Resources Chairman Ron Stollings, D-Boone, said the health care law was the beginning of reform and not the end. He thinks reforms will save money by making people healthier.

Still, he worried about state costs as the federal government's share of Medicaid begins to go down.

"It will be after those three years that the states will be crunched -- hit pretty hard, I'm guessing," Stollings said.

But Sen. Dan Foster, D-Kanawha, said choosing whether to expand Medicaid is a "false choice."

"It's hard to believe it would be a reasonable consideration to not take that money to help our people," Foster said.

If the state doesn't expand its Medicaid program, some people will be worse off than others.

On the upside, few low-income people would have to pay the tax penalty most other Americans will face if they choose not to buy health insurance.

There are also subsidies available for people making 100-400 percent of the federal poverty level. So, many low- and middle-income people will get help buying insurance if they want it.

But the worrisome group is people with income of less than 100 percent of the poverty level who don't have insurance. Right now, there are about 100,000 of those people in West Virginia.

Before the court ruled, they were going to get insurance when Medicaid expanded. Now, they might not receive Medicaid. They also are not eligible for subsidies because Congress intended for them to receive free Medicaid. So, while they won't have to pay a penalty for remaining uninsured, they could nevertheless remain uninsured. This population could create a huge hole in President Barack Obama's plan to insure most Americans.

Contact writer Ry Rivard at ry.rivard@dailymail.com or 304-348-1796. Follow him at www.twitter.com/ryrivard.

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