Michigan: SURPRISE!! 600,000 Medicaid recipients could be screwed by King v. Burwell as well!!

With all the fuss and bother about the impending King v. Burwell decision, many outlets have posted about the most obvious result of a plaintiff win: 6.5 million people losing their federal tax credits (although most of them keep mistakenly reporting it as 6.4 million).

Some of them have also reported on the secondary results: Another 6.5 million (give or take) facing massive premium increases next year (well beyond whatever increases they were already planning anyway).

A few (well, me, anyway) have even reported on a (admittedly unlikely, but still possible) tertiary consequence: An adverse ruling could even be made retroactive to January 2014.

And, just yesterday, there was a report on the potential negative ripple effect this would have on the rest of the local economy (hospitals, doctors, drugstores, etc.)

However, through all of this, there's one possible consequence which few, until now, seem to have thought would be an issue: Medicaid expansion.

The Medicaid expansion provision of the ACA is a completely separate section which shouldn't be impacted by King v. Burwell, other than peripherally (ie, some people who lose their policies could indirectly end up falling below the 133% FPL threshold as a result, and thus then qualify for expansion, etc). And in most of the expansion states, that's true.

However, in a few states such as Michigan...SURPRISE!!

LANSING, MI — Michigan's popular Medicaid expansion program will face an uncertain future if the U.S. Supreme Court strikes down a key plank of the Affordable Care Act this month.

A case before the nation's highest court seeks toinvalidate premium tax credits that more than 225,000 Michigan residents have used to purchase private health insurance through a federal exchange.

Those same tax credits are featured in a pending waiver the state must win from the Obama administration in order to continue Healthy Michigan, a federally-funded Medicaid expansion program has enrolled roughly 600,000 low-income residents since implementation but could be rolled back in 2016.

The short version is that unlike most of the expansion states which simply bumped up the eligibility income threshold and called it a day (as it should be), Michigan was one of the states which only agreed to expand Medicaid if it included tweaks such as small premiums/co-pays (and possibly a work requirement, not sure about that). In order to modify the terms of the expansion funding, however, the state needs to have a waiver approved by the federal grovernment. However, this waiver has to be re-approved every now and then, so...

After they've been on the plan for four years, those recipients must either pay higher out-of-pocket costs or purchase private insurance through an Affordable Care Act exchange using the aforementioned premium tax credits.

Under the 2013 law, the state must obtain federal permission for the 48-month cap by the end of 2015. Without a waiver, the statute calls on the state to begin notifying enrollees the program will be terminated at the end of April.

..."The case doesn't directly impact Healthy Michigan as it exists now or the nearly 600,000 Michiganders enrolled in the innovative program," she said. "However ... the second waiver that will eventually be needed does have an exchange component to it."

Of course, as with every other state, the King plaintiffs winning their case could be made into a complete non-issue by either Congress or the Michigan legislature...

Michigan lawmakers could ensure residents qualify for insurance tax credits by establishing a state-based health insurance exchange, but past efforts of that kind have failed in the GOP-led Legislature. At least one lawmaker has suggested Snyder consider an executive order.

...but so far neither one seems terribly likely to happen anytime soon.