While controversy rages in Washington and around the country over the Republican effort to kill Obamacare, Maryland leaders are anxiously watching in fear of what they may confront down the road.
Total repeal of the Affordable Care Act would deprive state government of $1.3 billion in Medicare and Medicaid payments next year — a staggering amount. Some 1.1 million Marylanders on Medicaid — most of them disabled, children or elderly — could be at risk of losing their health insurance.
That's a dire situation Gov. Larry Hogan hopes to avoid. He issued a statement while on an overseas trip to Israel voicing opposition to the Republican repeal effort in Washington. Other Republican governors are doing the same thing.
In Maryland, Obamacare has been a plus for large numbers of citizens who previously lacked health insurance.
A total of 421,000 Marylanders are now covered by subsidized private insurance or by the expansion of Medicaid under the ACA.
Baltimore County has seen a major drop in the number of people without health insurance. In 2013, 12 percent of county residents had no health care safety net. Two years later, that number totals just 5 percent.
This still is higher than the uninsured rates in neighboring Carroll, Harford, Howard and Anne Arundel counties but better than the uninsured rate in Baltimore City, 11 percent.
Giving so many people with meager incomes the chance to get health insurance is a huge positive. Many of these individuals hadn't seen a doctor in years and used to clog hospital emergency rooms when they got ill.
The benefits can be seen at Maryland hospitals, where the number of "uncompensated care" patients showed a dramatic decrease in two years, saving these medical centers a combined $311 million.
Hospitals such as Northwest, Sinai, St. Joseph and GBMC are just as nervous as their ACA patients over what Republicans in Washington may end up doing. An outright repeal of Obamacare would result in a loss to Maryland hospitals of $2.3 billion in Medicare and Medicaid funds.
Many hospitals would have to close or severely restrict activities. Most at risk are hospitals in rural parts of Maryland and those near urban centers. One national report estimates that 50 percent of rural hospitals would be forced to shut down if Obamacare disappeared.
Nursing home residents also would be in peril, since roughly half of those residents depend on Medicaid — the chief budget-cutting target of congressional Republicans.
It's a difficult situation for Maryland's state leaders. Hogan is already getting heat from potential gubernatorial rivals over his inertia, including from Baltimore County Executive Kevin Kamenetz and Baltimore County resident Ben Jealous.
Hogan could find himself in a bind. If Republicans in Washington repeal the ACA, the governor would have to decide what to do.
Should he sit idly while 421,000 newly insured Marylanders lose their coverage and others on Medicaid risk losing health care benefits?
Or should he do something anathema to Republican governors: support a substantial tax increase that continues health insurance coverage for all those Marylanders?
Minefields are everywhere for the governor. For instance, big insurance rate hikes have been proposed for next year under Obamacare.
If the rates are set too high by Insurance Commissioner Al Redmer, of Baltimore County, most of these people won't be able to afford health insurance. But if rates are too low, insurance companies may drop out of the Maryland market.
Either way, Hogan might have to get involved — a dicey situation for a governor about to start his campaign for re-election.