THOSE FOR WHOM WE'RE FOOTING THE BILL...:

The benefits and burdens of the Medicaid expansion are particularly great in states with the greatest number of low-income uninsured residents.

In Texas, the expansion would add 1.2 million people to Medicaid in the first year and cost the state $27 billion over 10 years, said Stephanie Goodman, spokeswoman for the Texas Health and Human Services Commission.

In Indiana, Republican Governor Mitch Daniels has decided to defer a decision about the Medicaid program to the next governor and Legislature. Expanding the program in Indiana, he said, would add 500,000 people to the rolls and cost the state $2 billion over 10 years.

Although states face a financial burden if they do participate in the program, low-income residents face living without insurance if the states do not. In those states that opt out, residents could be uninsured if their income falls below 100 percent of the federal poverty level but is greater than the state's threshold for Medicaid benefits, Salo said. In New Hampshire, that bar is 66 percent of the federal poverty standard.

For people whose income falls between 100 and 133 of the federal poverty figure, Salo said, subsidies under the health care act should be available to buy insurance on new exchanges in each state.

Restuccia said he foresees a gradually forming consensus in state capitals that Medicaid expansion is acceptable.

Initially, he said, "some states that have strong Republican governors and legislatures are not going to cooperate." But by 2019, Restuccia predicted, "we will see every state in the country having Medicaid expansion."

The benefits will begin to be seen as all stakeholders work to control costs, just as they are in Massachusetts, he said.

"It's hard to do this kind of work, but if one has the motivation and persists with it, it has a tremendously positive effect both on costs and quality," Restuccia said.

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