July 17--As states decide if they will try to extend Medicaid coverage to millions of low-income Americans, state hospitals might have a large seat at the table.

The U.S. Supreme Court preserved much of the national health care reform law. But the court also ruled states could opt out of a federal plan meant to expand Medicaid, the government health care program for the poor.

The expansion effort was meant to provide insurance to about 16 million low-income Americans, including about 130,000 West Virginians. The state and federal program already insures 420,000 West Virginians.

In Florida and Texas, Republican governors have balked at making Medicaid bigger than it already is. In both states, hospital associations have questioned their governors' decisions and argued the expansion can be a good idea.

Likewise, the West Virginia Hospital Association supports efforts to expand the Medicaid program.

That could be important: Eight of the state's 25 largest private employers are hospitals. That makes them the largest private employers in some communities. Some legislators also sit on hospital boards.

The association backs the Medicaid expansion even though the program's reimbursement rates are notoriously low. That's because West Virginia hospitals currently provide $740 million in charity care to the uninsured. Many of those uninsured people will be eligible for Medicaid if the state decides to expand the program.

But the head of the association isn't planning to pound on tables to get what he wants.

Instead, hospital association president Joe Letnaunchyn said the decision about Medicaid is "not something you can twitch your nose" and simply say is a good thing.

"We can put the full court press out there and say, 'Doggone it, you ought to expand Medicaid and do it in 2014,' " Letnaunchyn said, "and we may reach a point where it becomes irresponsible on our part because we're not the ones paying the tab. Because the state is the one eventually down the road that has to pick up that price."

State health care officials are trying to get answers to many questions about the Medicaid expansion and the ramifications of the Supreme Court ruling.

Democrat Gov. Earl Ray Tomblin has revealed his opinion, saying only that he is reviewing his options and "will always do what is in the best interest of all West Virginians."

The federal government would pick up the entire tab of the Medicaid expansion in the first few years. But, after 2020, states have to pay 10 percent of the bill.

West Virginia's share of the costs then is estimated to be about $80 million a year, although there have been no recent or detailed estimates. The state already spends about $850 million a year on Medicaid, and federal matching funds bring the total to about $3 billion.

One worry is that Congress won't hold up its end of the bargain. In that scenario, Congress would succumb to budget pressures of its own and pass the buck to states. Because each tweak is so expensive, that could be disastrous to some state budgets.

Republicans have criticized Tomblin's holding pattern and urged him to endorse congressional efforts to repeal the whole health care law that have so far been futile. On the other side, pro-expansion liberals have portrayed the choice to expand as an obvious and humane one.

Others have taken a wait-and-see approach.

"We're smart enough to know that you don't just go around putting a gun to somebody's head, saying, 'Let's implement this whole expansion,' without knowing what the other questions are," Letnaunchyn said.

Hospitals also have questions.

Medicaid coverage will help reduce the $740 million in charity care hospitals provide each year. But state hospitals also have to deal with other parts of the law. Some of those provisions will cost state hospitals more than $1 billion over 10 years in money the hospitals would have received under formulas and other policies that the health care law rewrote or added.

"It's hard to model what the exact impact will be; we haven't been able to do that yet," Letnaunchyn said.

There is also concern about whether doctors will be able to handle the surge of patients who may seek care once they have insurance.

And while the focus has been on Tomblin's position on Medicaid expansion, the decision could rest in part with the Legislature and others.

Legislative leaders in the Democrat-controlled House and Senate generally have seemed to lean toward the expansion, although they want to see more analysis.

"The moral of this story is that there are a lot of unknowns that everybody is trying to figure out," Letnaunchyn said.

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

___

(c)2012 the Charleston Daily Mail (Charleston, W.Va.)

Visit the Charleston Daily Mail (Charleston, W.Va.) at www.dailymail.com

Distributed by MCT Information Services