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Nobamacare
If any state declines to participate in the expansion, the Department of Health and Human Services (HHS) could strip that state of 100% of its Medicaid dollars. Every voter in that state would continue funding Medicaid through payroll taxes twice a month, but now would be subsidizing the other 49 states. Rejecting the expansion would thus be a political death wish for any governor or legislature.
This coercion is an unconstitutional violation of state sovereignty, so the Court struck down part of ObamaCare’s massive Medicaid expansion.
But there are no tax subsidies if HHS runs an exchange, so no incentive for people to flock to the exchanges; they’d pay full price. While many high-risk individuals would do so, it would still be vastly more expensive. Many will instead choose to pay the penalty (tax?) for violating the individual mandate.
Since HHS-run exchanges have no subsidies, for states refuseing to create exchanges, no employer in that state will be subject to that penalty. This means business owners will band together to lobby their state not to set up exchanges.
This will create an unworkable patchwork nationwide, between states with semi-socialized medicine and healthcare costs spiraling out of control, versus those with private-sector medicine. Expect doctors, insurers, and providers to flock to these friendlier states, creating an increasingly unbalanced system. Then ObamaCare will start coming apart at the seams, and momentum will build to repeal and replace.
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