Dave Helling | Missouri, Kansas face Medicaid expansion dilemma

Kansas and Missouri have a difficult choice to make.

Last week, the Supreme Court ruled that states cannot be forced to expand their Medicaid programs as part of the Affordable Care Act. Washington is free to expand the program, the court said, but it can’t threaten to cut off existing Medicaid spending to states that don’t participate.

The states exhaled. The feds pick up about 57 percent of the cost of Medicaid, which is health insurance for the poor. Losing that money would have forced states to either dismantle their budgets or shut down the program.

But Kansas and Missouri — and the 48 other states — now must decide if they’ll expand Medicaid because they want to, not because they have to.

Expanding Medicaid is a key part of the Affordable Care Act’s effort to provide health coverage to the uninsured. This spring, the Congressional Budget Office said expanding Medicaid would provide new coverage to 17 million people by 2020, about half the number of uninsured the new health care law aims to protect.

So Washington has offered a huge incentive to the states to expand Medicaid: For the first three years, the feds will pay for it. After that, however, states have to pick up some of the additional costs — and by the end of the decade, they have to pay 10 percent of the expansion.

So you can appreciate the dilemma: The states must come up with additional millions to take advantage of Washington’s offer of billions.

Kansas would have to kick in an extra $156 million from 2014-2019 in order to get $3.9 billion from Washington, according to a recent study by the Kaiser Family Foundation. Missouri could get $9.5 billion in extra Medicaid funds over those six years — but only if it ponies up $385 million of its own.

So far, several states led by Republican governors have said “no thanks.” You can hear similar noises from legislative leaders in Kansas and Missouri.

If enough states refuse to expand Medicaid, it would shave tens of billions of dollars from the federal deficit over the next decade. At the same time, if states stay out of the expansion, their taxpayers will essentially be sending money to Washington to help expand Medicaid in other states.

Will GOP states agree to pay for more Medicaid in Democratic states? Will lawmakers decline to spend an extra dime to get an extra dollar? We may soon find out.

The Affordable Care Act, of course, might still be repealed. But if not, Kansas and Missouri lawmakers will face a tough choice next year.