Faith leaders were an important group pushing red state leaders to accept Obamacare’s Medicaid expansion. And with open enrollment for Medicaid and the law’s insurance marketplaces inching closer, they’ll be crucial to making sure that Americans know how, where, and when to sign up.

To that end, Maryland officials are currently holding a summit with over 150 faith leaders in which they explain the nuances of the law — and urge religious leaders to distribute that information by educating their congregants and communities. Faith leaders are enthusiastic about the plan, since their day-to-day dealings with their communities gives them a unique perspective on Americans’ needs and struggles:

The Rev. Janet Craswell, of the Salem United Methodist Church in Brookeville, described the summit as very helpful. Although her church is in a small Maryland community, Craswell said she has been hearing from a wide variety of people who will be impacted by the overhaul, including families with unemployed and uninsured young adults, people with disabilities and small business owners who are confused and concerned about how the law will impact their businesses.

“We see people every day,” Craswell said. “I mean, we are dealing with people week to week, and we’re also dealing with people at the point of crisis where they’re in hospitals and in hospice and they’re having to deal with major life issues.”

In fact, coordinating Obamacare enrollment efforts with faith leaders could be great news for another population that has largely been ignored in all the hubbub and politics of the expansion: Americans who already qualify for the program, but have never enrolled. In a 2006 report, the Commonwealth Fund estimated that 62 percent of Medicaid or CHIP-eligible children were not enrolled in either program, and 66 percent of Medicaid-eligible low-income parents were not enrolled.

Much of that discrepancy has to do with underwhelming state outreach efforts stemming from a lack of adequate funding, as well as the reality that many Medicaid-eligible populations simply don’t know they have the resource available to them. “Even in states that have more of a commitment to bringing new populations in, they don’t have the budget to do outreach and take out ads,” said Melinda Dutton, a partner at a health consulting firm assisting states with Obamacare implementation, in an interview with American Medical News.

But with the renewed national push for Medicaid enrollment ramping up this year, some health advocates hope that these previously unenrolled Americans will get swept up in the effort and “come out of the woodwork.” That’s where faith leaders are crucial to the undertaking, since they have greater access to the rural or isolated communities that Medicaid may have overlooked.

For example, the homeless — or those on the cusp of entering transitional housing programs — often do not enroll in Medicaid due to barriers such as a lack of proper identification or a Social Security card. These populations also tend to distrust government institutions — but faith leaders and community organizations could help walk them through the process in a way that the government can’t, helping secure their medical stability. And with over 25 million Americans expected to gain coverage under Obamacare in the coming decade, state, federal, and public health officials will need all the help that they can get.

In light of Republican-led states’ entrenched opposition to Obamacare’s Medicaid expansion, safety net hospitals around the country have expressed fears that they could go bankrupt as their government funding gets cut. On Monday, the Center for Medicare and Medicaid Services (CMS) announced that it would help these embattled hospitals by paring back planned cuts to their federal reimbursements.

In an attempt to cut government health expenditures, Obamacare included fairly deep cuts to so-called “disproportionate share” hospitals’ (DSHs’) — safety net facilities that cater mostly to the poor and uninsured — reimbursement payments. These cuts were intended to be offset by an influx of newly-insured Americans covered under the states’ expanded Medicaid programs.

But since the Supreme Court ruled the expansion optional, red states with a large number of low-income and uninsured residents have largely refused to take part in the Medicaid expansion, thereby creating a disastrous funding problem for safety net hospitals in these states. The CMS’s new proposed regulations represent an effort to avert those disastrous cuts as states get their acts together:

The Centers for Medicare & Medicaid Services proposed on Monday that for the next two years, the DSH dollars be reduced based partly on a state’s percent of uninsured residents (states with the lowest percent of uninsured receive larger reductions). CMS also seeks in the proposal to protect state DSH funding that is used to increase coverage under Medicaid demonstration waivers. [...]

“… since some states have yet to decide whether to expand Medicaid, this proposed rule will not discourage expansion, nor will it penalize hospitals in those states that have yet to make a decision,” [Rick Pollack, executive vice president of the American Hospital Association,] said.

However, CMS’s new proposal is a funding band-aid, not a permanent fix. The far more responsible and efficient way to take the heat off of America’s safety net hospitals — while securing low-income Americans’ medical and financial well-being — would be for highly uninsured states to accept the health law’s generous funding to expand Medicaid.

In fact, that’s exactly why some GOP governors such as Arizona’s Jan Brewer and Florida’s Rick Scott have reversed course and decided to endorse the Medicaid expansion — because hospital associations in their states have been warning that noncompliance in the face the upcoming payment cuts would cost them tens of billions of dollars and possibly force them out of business, leaving millions of America’s poor without recourse for medical care. Unfortunately, not all Republican state leaders and legislators seem to be swayed by that argument, forcing the CMS to take action and stave off safety net hospitals’ fiscal ruin.

But seeing as even the GOP governors who have endorsed expansion are struggling to convince skeptical legislators in their own party, the temporary fix is crucial to making sure that safety net hospitals — and the millions of poor Americans who rely on them — don’t end up as the collateral damage of a political fistfight over Obamacare. Arizona, Florida, Texas, and Louisiana — four GOP states that appear increasingly unlikely to expand Medicaid this year — have close to 12 million uninsured residents alone, approximately half of whom live below 138 percent of the Federal Poverty Level (FPL) and would likely gain Medicaid coverage under the expansion.

Kentucky Gov. Steve Beshear (D) announced on Thursday that he would accept federal money to expand his state’s Medicaid program under Obamacare. That brings the total number of states participating in the optional expansion up to either 22 or 18 (plus the District of Columbia) — depending on the actions of some state legislatures that are still debating the issue.

According to a press release from Beshear’s office, the governor called the move “the single-most important decision in our lifetime for improving the health of Kentuckians” and something that is “in the best interest of the Commonwealth and its citizens.” He also stated that an analysis of the expansion’s costs revealed that non-participation would be mean losing money for the state, echoing the fiscal argument made by West Virginia Gov. Earl Ray Tomblin (D) last week.

Beshear certainly has his numbers right. According to the Kaiser Family Foundation, Medicaid expansion will cut Kentucky’s high uninsurance rate by over 55 percent, and the price of noncompliance could be as high as $40 million by 2021. Considering upcoming cuts to safety net hospitals that serve poor residents and the reality that nearly one in three Kentuckians living below 139 percent of the Federal Poverty Level (FPL) is uninsured, that would have proven to be an unaffordable cost from both a fiscal and a public health standpoint.

What’s less clear is how much difficulty Beshear will have with gaining the support of lawmakers in a state that has elected ardent Obamacare opponents like Sens. Mitch McConnell (R) and Rand Paul (R). Democrats hold an 11-seat edge in Kentucky’s state House, while Republicans hold an 11-seat edge in the state Senate. Convincing those 11 Republican state senators could be difficult, considering that several other GOP governors in highly uninsured states are still battling their own party members to cooperate with the health law’s Medicaid expansion.

Texas lawmakers have until midnight on Thursday to negotiate a deal on the 2014-2015 state budget before the current legislative session ends. But they may find themselves in town for a bit longer if some Tea Party lawmakers in the state House have their way and force a special legislative session over a Republican-backed rider regarding Obamacare’s Medicaid expansion — even though the amendment wouldn’t actually expand Texas’ Medicaid program, but simply “open the door to discussions with the federal government to expand health care coverage for the state’s poorest adults.”

The threats from Texas Tea Partiers make it even more unlikely than it already was that the Lone Star State will pass anything resembling a Medicaid expansion — or even future promises to simply talk about the issue — this year. As Texas Republicans — who introduced the rider — point out, the provision is simply a declaration that state and federal officials will discuss how to help the state’s poorest residents gain coverage in a way that hews to conservative, “free market principles” regarding health entitlements in light of upcoming cuts to safety net hospitals and Texas’ massive poor and uninsured population. But those arguments have failed to sway some in the Tea Party caucus, who view any talk of Medicaid at all as a sell-out to President Obama’s landmark health reform law:

“If the budget expanded Medicaid, conservatives in the House would vote the budget down,” said state Rep. Van Taylor, a Tea Party favorite from Plano. He said conservative Republican members of the House are “absolutely prepared to go to the mat” and return for multiple special sessions to prevent any semblance of Medicaid expansion.

State Rep. John Zerwas, R-Simonton, said House Bill 3791, which he filed to present the Legislature with an alternative way to expand health coverage to the state’s poorest adults without expanding Medicaid, would probably not move out of the lower chamber by the House’s midnight Thursday deadline, therefore the rider was one of few — if not the only — remaining legislative vehicles for the Legislature to weigh in on the issue.

“If people took the time to read the rider they would recognize that it’s not a Medicaid expansion,” he said. “They would understand clearly that it is a lot of, frankly, conservative principles.”

In fact, HB 3791 — a GOP alternative to Obamacare’s Medicaid expansion that would have covered Texas’ poorest by giving them subsidies to buy private insurance — was already doomed to fail in the House. This rider is simply a last resort that promises future negotiations on the issue. It actually also endorses extremely regressive approaches to expanding the safety net, including possibly block-granting the state’s Medicaid program. But, as the debate over Obamacare has become increasingly disconnected from reality, some members of the Texas Tea Party are willing to hold the state’s entire budget hostage over a measure endorsing policies that they have historically supported.

While this recent infighting is something of a new low in the Medicaid expansion debate, GOP hypocrisy regarding the health reform law certainly isn’t. Receiving federal funding in exchange for expanding and privatizing Medicaid programs — which the Obama Administration has signed onto — is usually a GOP-endorsed policy. In fact, Texas Gov. Rick Perry (R) struck a massive deal with federal officials in 2011 allowing him to move close to a million Medicaid beneficiaries into private, managed care. Perry heralded the move at the time, but has refused to accept an expanded version that same deal now that it’s a priority for the Administration and necessary for effective Obamacare implementation.

Only 35 percent of Texans living below 139 percent of the Federal Poverty Line (FPL) are covered by the state’s Medicaid program. 43 percent are uninsured.

Florida Gov. Rick Scott (R), an ardent Obamacare opponent, surprised health care reform advocates earlier this year when he endorsed expanding his state’s Medicaid program. But the governor can’t single-handedly add more low-income residents to the Florida’s Medicaid rolls; the proposal still needs the support of the GOP-controlled legislature, which has been fighting over it for the past several months. And now that the state’s legislative session has come to an end, time has run out for the estimated 1.3 million Floridians who stood to gain health insurance under Obamacare’s Medicaid expansion.

On Friday, the legislature concluded without passing a budget that includes funding for expanding Medicaid. That means Florida won’t expand Medicaid in 2014 unless lawmakers convene a special session sometime later this year. Democrats in the state are calling for that special session to focus on pushing through a compromise, but the Republican-dominated legislature may not comply. The decision to refuse the expansion will leave about one million Florida residents uninsured.

As Wonkblog’s Sarah Kliff notes, this situation isn’t unique to Florida. In other red states, the Republican governors who have chosen to endorse Medicaid expansion are also struggling to get the support they need from the other members of their party to advance the policy:

This isn’t a phenomenon reserved to Florida. In Ohio, Gov. John Kasich (R) is having trouble moving the Medicaid expansion he supported through the state’s Republican controlled-legislature. Similar fights are playing out in Arizona and Michigan, where Republican governors find themselves in the relatively odd position of trying to sell Obamacare to state legislators of their own party.

In a way, this is a bit surprising. No one ever expected to hear Scott extoll the benefits of President Obama’s signature legislative accomplishment. That being said, the Medicaid expansion is a really big deal for state budgets — the budget that Scott is charged with overseeing. If his state had participated in the Medicaid expansion, the Urban Institute estimated it would bring $66 billion of federal funds into the state over the course of a decade.

That same burden doesn’t rest so heavy on state legislators. States and hospitals tend to cover much of the country’s uncompensated care and unpaid medical bills. Meanwhile, state legislators have faced intense pressure over this vote. In Ohio, my colleague Sandhya Somashekar reported on one group that went door-to-door collecting signatures from voters pledging to thwart reelection efforts should lawmakers there vote to expand Medicaid.

The politicized in-fighting over Obamacare has pitted governors against legislatures across the country, as many Republicans still refuse to cooperate with health reform no matter what the cost. But for the residents in states like Florida, that political reality comes with especially significant consequences.

Florida, where about one in five people lack health care, has one of the highest rates of uninsurance in the nation. Previous studies have estimated that it’s one of the states that would benefit the most from the health reform law’s Medicaid expansion provision. Hospital groups and faith leaders in the state have both lobbied for expanding Medicaid, which they characterize as a “pro-life” program. Nevertheless, even though Rick Scott was able to put aside politics to prioritize health care for low-income Floridians, his fellow Republican lawmakers haven’t been able to do the same.

West Virginia Gov. Earl Ray Tomblin (D) announced in a press conference on Thursday that his state would take part in Obamacare’s optional Medicaid expansion, calling the decision “the best choice for West Virginia.” But many states still remain up in the air with their decisions, either because they haven’t decided yet or because state executives and legislators are at odds with each other on the issue — and time is running out.

Speaking at St. Francis hospital and flanked by nurses, doctors, and hospital administrators, Tomblin laid out the medical and financial case for expanding Medicaid eligibility — a conclusion that he reached after commissioning a study to examine such a move’s effects on West Virginia. “Expansion will allow us to provide insurance coverage to 91,500 West Virginians,” said Tomblin.

Indeed, West Virginia has much to gain and very little to lose by embracing the Obamacare provision. The state has abysmal health demographics, and over half of West Virginia’s uninsured population lives below 138 percent of the Federal Poverty Level (FPL). These poor and vulnerable populations would gain access to health coverage under the Medicaid expansion, leading the Kaiser Family Foundation to conclude that expansion will reduce the number of uninsured West Virginians by a staggering 67 percent.

Those numbers likely led Tomblin to his decision. But the moderate Democrat has an advantage that governors of other conservative — and highly uninsured — states don’t: the almost assured support of his legislature. Democrats hold a supermajority in the state Senate and an eight seat edge in the House of Delegates, and both of West Virginia’s U.S. senators also support expanding Medicaid, making intraparty barriers unlikely.

The same cannot be said of Republican Govs. Jan Brewer (AZ) and Rick Scott (FL), who have been lobbying for Medicaid expansion after intense pressure from hospital associations and advocates for the poor. Their Republican-controlled state legislatures have been bending over backwards to stop it from happening. Although there is no hard deadline for expanding Medicaid under Obamacare, many of these states’ legislative sessions are quickly coming to an end — meaning that if no agreement is reached soon, they won’t receive the additional federal funds and won’t be able to extend coverage to low-income residents for at least the first full year of Obamacare implementation.

Texas and Louisiana face similar issues. Although some GOP lawmakers in those states are contemplating Arkansas Gov. Mike Beebe’s (D) alternative “private option” — which would take federal money and use it to help an expanded Medicaid pool buy private insurance — those efforts also remain in limbo, as former and current Republican presidential aspirants Govs. Rick Perry (TX) and Bobby Jindal (LA) have oscillated between flat-out rejecting expansion and being coy about their intentions.

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Medicaid gets a bad rap from a lot of conservatives for poor access to health care and poor health outcomes. It’s one of the main arguments in favor of schemes to cut Medicaid funding and block grant it to the states, on the grounds it will promote efficiency and innovation in the program.

But a new study in the Journal of General Internal Medicine found that when you compare the proper groups, Medicaid actually does a better job delivering access and affordable coverage than either private coverage or Medicare.

As Aaron Carrol summed up at the Incidental Economist, the study focused on the underinsured — that is, people on insurance plans that just aren’t very good — rather than those who have no insurance. More importantly, it only looked at people at or below 125 percent of the poverty line. That’s important because the problem with the studies showing Medicaid delivering inferior results to private coverage is that it’s difficult for their comparisons to avoid the apples-to-oranges problem. Medicaid is meant for poorer Americans — you have to be below a certain income threshold to qualify for it — but private coverage is available to the poor and well-off alike. It’s a matter of basic economic logic that the private plans only the well-off can afford will will provide much better access and quality care then the plans the poor can afford as well. Products poor people can afford tend to be poor products.

That’s why safety net programs like Medicaid, which provide people more assistance than they could afford in a pure free market world, are so important. And why, when the proper apples-to-apples comparison is made between poor people on private insurance and poor people on Medicaid, the latter’s performance improves remarkably:

For the purposes of this study, underinsurance was defined as (1) having out-of-pocket expenses that were more than 5% of household income, (2) delaying or failing to get needed medical care because of cost, or (3) delaying or failing to get needed medications because of cost. This study specifically looked at adults who had full-year continuous coverage in some form, but had an income less than 125% of the poverty line. They specifically wanted to know how many of those people were still underinsured.

They found that more than a third of these adults were underinsured. What’s more is what kind of insurance left people underinsured. More than 65% of those people on Medicare were underinsured. More than 37% of people with private insurance were underinsured. But only 26% of people on Medicaid were underinsured. People who were underinsured were more likely to be White, in poor health, and unemployed. Even after adjusting for these factors, those on Medicaid were significantly less likely to be underinsured than those on private insurance (odds ratio 0.22).

The gap between Medicaid and Medicare, meanwhile, is most likely due to Medicare’s higher co-pays and other forms of cost-sharing. While this generally won’t be a problem for seniors in the middle class and up, it can be difficult for poor seniors to meet their share of the costs.

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The GOP-controlled Florida state house on Friday passed a Medicaid “expansion” bill that would substantially burden the state’s budget by rejecting any federal funding. It would open up private insurance access to a very select pool of Florida’s low-income residents — but it could force these vulnerable Americans to forgo care, despite their new coverage, by giving them insufficient subsidies and making them choose between private high-deductible health plans (HDHPs) that also come with costly premiums.

Unlike its companion bill in the Senate — which has been endorsed by both Gov. Rick Scott (R) and the Obama Administration — the House’s bill would expand coverage to a mere one-tenth of the 1.1 million poor Floridians who would have gained access under a more expansive effort. That’s because the bill only addresses Americans living at or below the Federal Poverty Level (FPL), instead of Obamacare’s more ambitious limit.

Now that the bill has passed, a showdown between the House and Senate is likely. Although both bills would privatize Florida’s Medicaid program, the Senate’s version would insure all poor Floridians up to 138 percent FPL. The House version, on the other hand, will concentrate on extending insurance to poor single moms, poor working parents, and disabled adults by giving them a flat $2,000 per year subsidy — but would not extend coverage to poor working adults in general. Although Republicans insisted the pared down bill was necessary to contain rising health costs, critics argued that it is unfair to ask the poorest Americans to pay over three times the monthly premium as state workers and legislators, pointing out that there is bipartisan support for the Senate’s alternative bill:

The House plan would use $237 million in state funds to give recipients $2,000 a year to choose their own private insurance plans. The plans would require a $25 monthly premium and likely have high deductibles, which Democrats said many families would not be able to afford.

In contrast, House members covered by the state insurance plan spend $8 a month.

“There’s very little you can buy,” said Rep. Mia Jones, D-Jacksonville. “This population will not be able to take this product that has been crafted for them and not be able to do anything of value with it.”

House Democratic Leader Perry Thurston warned that members were missing a chance for bipartisanship, noting the Senate had already put aside their differences.

“We have a governor who has disagreement with the president of the United States but they came to a bipartisan resolution and put aside those differences,” Thurston said. “Why? Because of the importance of saving lives.”

As Jones points out, since this bill would provide Floirida’s uninsured with insurance that they still won’t be able to use, the $237 million price tag is largely a waste. The average annual deductible in HDHPs has been rising steadily as more employers rely on them, ranging anywhere from $1,100 for an individual to $2,500 for a family in 2012. By contrast, the average annual out-of-pocket health care costs for American households is expected to exceed $3,000 by 2014. So the $2,000 annual subsidy wouldn’t end up going very far at all. This would present a problem for any family trying to afford health coverage — but for the particularly vulnerable populations that the Florida House’s bill seeks to cover, it could be catastrophic. Low-income Americans have specialized health care needs that, in many cases, are simply not covered by cheaper private health plans.

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Novartis Pharmaceuticals Corp. isn’t having the greatest year — and things just got much worse for the drug giant. In a civil suit that builds on a separate, sealed whistleblower case, federal prosecutors charged Novartis on Wednesday morning with paying out kickbacks in an effort to get pharmacies to switch kidney transplant patients’ anti-transplant rejection generic drugs with the brand-name Novartis product Myfortic.

The scope of Novartis’ alleged fraud is staggering. In the civil complaint, prosecutors charge that the company’s U.S.-based wing “used a program of rebates and discounts to boost sales of its anti-rejection drug.” Since Myfortic is far more expensive than its generic counterparts, this market share-gouging cost government health entitlements such as Medicare and Medicaid “tens of millions of dollars in reimbursements to pharmacies for which they were never entitled,” with Myfortic sales at companies that received the bribes totaling over $100 million. Some of those pharmacies allegedly received kickbacks making up a full 20 percent of their total Myfortic sales, while the U.S. government drove an outsized 47 percent of the drug’s total sales by specialty pharmacies.

If the allegations are true, then not only did Novartis brazenly defraud the United States government — the corporation and its co-conspirators also compromised public safety and patient health. As the civil complaint states, “Hundreds, possibly thousands, of transplant patients have undergone switches in their medication as a result of the recommendations from pharmacies that were based on undisclosed financial, rather than independent critical, considerations.”

Medicare and Medicaid fraud by pharmaceutical companies is the main driver of Justice Department settlements under the False Claims Act — the same statute that Novartis is being sued under. In 2012 alone, the Justice Department nabbed $3 billion from doctors and pharmaceutical companies that swindled the public entitlement programs by charging the government more than their services were actually worth. In fact, in 2010, Novartis had to settle a separate case involving kickbacks and misuse of drugs, paying out $420 million in criminal and civil damages. The newest slate of charges against the drug giant prompted Manhattan U.S. Attorney Preet Bharara to call Novartis “a repeat offender.”

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Republicans in Benton County, Arkansas are not happy that their state legislators have agreed to expand Medicaid under Obamacare. In this month’s newsletter, columnist Chris Nogy encouraged his fellow Republicans to utilize their 2nd Amendment rights to make sure that lawmakers — particularly Republicans who vote with Democrats — are held accountable:

So what do we do?  While I believe that we as a party are done in Arkansas after this, if there is ANY hope of our survival, it is going to take not being forgiving.  Not only for past actions, but to show those who will come in the future that the cost of failure to do the thing they were elected to do will be significant.  We need to be making a point of this failure from this moment on.  We need to make a public statement from our groups that we no longer support those who turned on us, that we will NOT be working to their re-election, that we will be actively seeking replacements, and perhaps even working towards recall.  We as the Party have to stand up and say ‘no more – you were given a job, you campaigned on the promise to do this job, you had the ability to do this job, you had the votes each time to do this job, and yet for no legitimate reason you betrayed the trust put in you by the electorate and you are now completely and permanently politically finished.’

We need to let those who will come in the future to represent us that we are serious.  The 2nd amendment means nothing unless those in power believe you would have no problem simply walking up and shooting them if they got too far out of line and stopped responding as representatives.  It seems that we are unable to muster that belief in any of our representatives on a state or federal level, but we have to have something, something costly, something that they will fear that we will use if they step out of line.  If we can’t shoot them, we have to at least be firm in our threat to take immediate action against them politically, socially, and civically if they screw up on something this big.  Personally, I think a gun is quicker and more merciful, but hey, we can’t.

Nogy’s wife is the group’s secretary, and apparently she included his “scathing” essay without permission. Tim Summers, chair of the Benton County Republicans, issued a statement clarifying that “the letter was not approved and Mr. Nogy had no authority to submit through the newsletter.” State Sen. Jim Woods (R) said he was “embarrassed” for the Benton County Republicans, and state Rep. Micah Neal (R) called the column “scary,” adding, “I don’t appreciate it.”

Such heated rhetoric from the Arkansas GOP is not new. Last week, state Rep. Neal Bell (R) tweeted that he bet the “cowering liberals” in Boston were “wishing they had an AR-15 with a hi-capacity magazine.” Arkansas House Speaker Davy Carter (R) issued a public apology to Boston on behalf of Bell’s insensitive remark, and Bell ultimately offered his own apology.