Molly Messick reports last week’s Supreme Court ruling on the federal health care overhaul left states with important decisions to make.  One of the main questions is whether to go along with the Affordable Care Act’s Medicaid expansion.

So far, Idaho Gov. C.L. “Butch” Otter is not among the ten Republican governors swearing off the expansion.  But if Idaho does go that route, a sizable percentage of Idahoans who live below the poverty line could find themselves in a kind of limbo with respect to the law.

This graphic from The Washington Post lays out the problem.  If states opt in, all residents with incomes up to 133 percent of the poverty line will be eligible for Medicaid coverage.

In many states that might opt out, however, there would be a gap between the poorest of the poor — who the states already cover with Medicaid — and those who earn too much to qualify for Medicaid, but whose incomes leave them below the poverty line.  Anyone stuck in this middle ground still would not qualify for Medicaid under the old rules.  Nor would they get the subsidies under the new rules.

In Idaho, the number of people who fall into that gap could be significant.  Why?  Let’s use a two-person family — one adult and one child — as our example.  In that case, the adult is Medicaid-eligible in Idaho only if the family’s income is $251 per month or less. That works out to $3,012 annually, which is just under 20 percent of the 2012 federal poverty guideline.

Parents who fall above that 20 percent threshold but below the federal poverty line would be left without Medicaid eligibility, and without access to subsidized private health plans.

Idaho Department of Health and Welfare spokesman Tom Shanahan says agency officials are hopeful the Centers for Medicare & Medicaid Services (CMS) will address that no-man’s land that now exists in the law.  He says CMS originally wrote guidance for states under the assumption that all would expand their Medicaid programs.  However, the Supreme Court’s decision makes it much simpler for states to opt out of that expansion.

While the Department of Health and Welfare awaits guidance from CMS and state leaders, it has assigned a Utah-based consulting group the job of assessing the population that would receive coverage if the state does elect to expand its Medicaid program.  A report is due mid-August.

In all of this, it’s worth noting that Idaho’s Medicaid eligibility thresholds have not budged since the mid-1990s.  The state adopted the most restrictive eligibility level allowed under the 1996 welfare reform law, Shanahan explains, and hasn’t changed the dollar amount since.  “Idaho has always had a fairly restrictive Medicaid program,” he says.