Corbett's spokeswoman Christine Cronkright said "revenue generation is certainly important," but the administration decided its "primary focus" would be getting more flexibility in the program to make it more sustainable.

Corbett's administration has said repeatedly that federal officials have left their questions about an expanded program unanswered. As recently as May 30, the administration was asking Washington for flexibility to keep children from low-income families in the CHIP health insurance program, rather than possibly moving them to Medicaid.

Children already routinely move in and out of Medicaid and CHIP, Hoover noted. The movement occurs when parent's income levels dip or rise. He also said federal law mandates states use Medicaid for the most needy children regardless of whether they expand or not.

"This is something Pennsylvania has had to plan for since 2010," Hoover said.

The governor gets policy support from some conservative groups. The free-market oriented Commonwealth Foundation says expansion just puts more people into a failed program many doctors don't accept. "The problem is the Affordable Care Act doesn't give us solutions to the root problem of care being too expensive," said policy analyst Elizabeth Stelle.

She also questioned how the additional federal spending would increase economic activity. More government spending, she said, means more taken out of someone's pocket.

A year of delay

While think tanks, the governor and lawmakers trade barbs and studies, many working poor living without insurance, are making tough choices between basics such as food and utility payments or hospital and doctor bills.

"I hear about it all the time," said Good Shepherd Rehabilitation Network patient accounts manager John Sipko. "They ration their medicine because they can't afford it."

While Liliana Hernandez of Allentown waited for a bus last week, she did the math for her eye care — $165 for a visit to her eye doctor and another $200, when she can afford it, for her prescription drugs. It was ironic to her that when she was working, she didn't have time to get to her doctor, she said. Now that she's unemployed, she has the time, but no coverage and no income.

There's an additional blow to the most needy people: Since Obamacare anticipated that Medicaid would be expanded universally, it made no other provision for the poor to get coverage. So if their income is less than the federal poverty level, they likely won't get Medicaid and they won't qualify for subsidies to buy private insurance.

That's why it's a disappointment to people like Letcher, the clinic medical director, to see the political haggling over something as important to her and her patients as Medicaid expansion. It means that if those working people in her clinic waiting room lived in expansion states like Maryland or New Jersey, they'd likely be covered beginning next year.

But in Pennsylvania, the working poor still don't know if relief is on the way.

"It's a whole year of delay," she said.

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