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It’s 7:30 on a crisp fall morning in downtown Philadelphia. Homeless men sleep beneath dingy blankets near LOVE Park as men and women in business suits walk briskly past an idling bus that’s nearly unnoticeable despite its size.

Parked just a stone’s throw from City Hall, the bus is filled with passengers about to embark on a two-hour ride to Harrisburg. Once there, they will go to the Capitol to protest Gov. Tom Corbett’s refusal to expand traditional Medicaid coverage under the Affordable Care Act. Why the journey? Because despite the furor over website malfunctions since the debut of the federal Healthcare Marketplace, these protesters believe that the refusal of 25 states to expand Medicaid to cover more people is the biggest threat to the Affordable Care Act’s successful implementation. Pennsylvania is one of those states.

Despite their best efforts to call attention to the issue, the topic of Medicaid expansion has gone virtually unnoticed in the partisan fight over the Affordable Care Act.

According to the Urban Institute, the 25 states’ refusal to expand Medicaid could leave 6 to 7 million low-income people uninsured nationally, and Pennsylvania would be hit especially hard. According to estimates provided to me by the U.S. Department of Health and Human Services, more than 1.1 million of Pennsylvania’s uninsured and eligible population may qualify for either tax credits to purchase coverage in the Marketplace or for Medicaid if Pennsylvania expanded Medicaid coverage under the Affordable Care Act. That amounts to 92 percent of the state’s uninsured.

To encourage states to expand Medicaid, the federal Centers for Medicaid and Medicaid Services (CMS) made funding available for states to draw.  The initial estimate of what Pennsylvania would draw to expand Medicaid to uninsured state residents with incomes under 133 percent of the federal poverty level in calendar years 2014, 2015, and 2016 was $6.1 billion dollars, according to Department of Public Welfare spokesperson Kait Gillis. That money would have funded 100 percent of the services to those individuals. However, Gillis said there would be administrative costs the state would have to pay.

One thing is certain: With a governor who is willing to refuse billions in federal money to fully fund the Medicaid expansion in its first three years, and additional federal funding to pay 90 percent of the expansion costs thereafter, the state’s uninsured are in trouble.

Without the Medicaid expansion, which was intricately tied into the original design of the Affordable Care Act, other parts of the law simply will not work as intended. For example, there are about 400,000 working poor Pennsylvanians who will not qualify to sign up for plans on the federal Healthcare Marketplace because they were supposed to be covered by the Medicaid expansion. Hospitals will lose federal reimbursements for uncompensated care because those costs were supposed to be covered by the Medicaid expansion.

Philadelphia, where 15 percent of its residents have no health insurance, will be especially hard hit, activists say.

That’s why Tyrone McCall, a soft-spoken man with a crutch and an easy smile, joined the protest. McCall, who is disabled due to a bad hip and other health issues, began volunteering with the Philadelphia Unemployment Project when the agency helped him out of foreclosure in 2008.

“The Affordable Care Act wasn’t meant for people to be left out,” McCall said. “That’s what not expanding Medicaid does… We’re taking that information and letting them know you should be included no matter what. The way Corbett is doing it is for only the few, not the many, and that’s not the way it’s supposed to be.”

Corbett’s alternative to expanding Medicaid to cover more people is modeled on the one offered by Arkansas Gov. Mike Beebe. But Corbett’s plan has a twist. Instead of simply expanding Medicaid to cover more people, Corbett wants to use the federal Medicaid money to implement a sort of health-care-for-work program. Under Corbett’s proposal, Pennsylvanians could get private health insurance under broader Medicaid eligibility guidelines that include adults making up to 133 percent of the federal poverty level, or about $31,000 for a family of four. Corbett also wants to decrease benefits for able-bodied adults who already are on Medicaid and require the unemployed and able-bodied who are seeking Medicaid coverage to do work searches through an online job clearinghouse set up by the Corbett administration.

“He wants to set up work requirements for Medicaid and also to install premiums,” McCall said. “These are people who don’t have a job. It wasn’t meant for them to be excluded. He just wants to make it CorbettCare and not ObamaCare.”

Healthcare advocates say Corbett’s plan is tantamount to hostage taking, because it turns a healthcare program into a welfare-to-work program of sorts, and imposes premiums on people who earn below 100 percent of the federal poverty level, which is not currently allowed by federal law.

The Corbett administration, in turn, has said Pennsylvania can’t afford to expand Medicaid in the way the Affordable Care Act requires, even though the federal government will fully pay for the expansion in the early years and most of it in later years.

In the meantime, the poor are caught in the middle of a war that many don’t know is being fought. According to one worker who is intimately involved with helping people to obtain healthcare, many of Philadelphia’s working poor don’t even know who the governor is. No matter. There are things they should know besides his name.

The poor should know that Corbett’s opposition to the Affordable Care Act dates back to his days as state Attorney General, when he sued the federal government in an attempt to dismantle the law. They should know that Corbett’s refusal to accept the federal Medicaid money has achieved what Corbett failed to do through litigation: At least for the moment, it has crippled the Affordable Care Act in Pennsylvania.

And with the 2014 gubernatorial election approaching, there is one other thing Pennsylvania’s poor should know. If ours remains one of the states that fails to expand Medicaid, we all should do our best to forget Tom Corbett’s name again—especially when it’s time to cast our votes.

This version includes new information submitted by the Pa Dept. of Welfare. The amount of money the federal government made available to Pa. for Medicaid Expansion was $6.1 billion dollars.