State officials say thousands of people with medical problems are in danger of losing coverage as the Obama administration winds down one of the earliest programs in the federal health care overhaul.

At risk is the Pre-Existing Condition Insurance Plan, a transition program that has turned into a lifeline for the so-called "uninsurables" — people with serious medical conditions who can't get coverage elsewhere.

The health care law capped spending on the program, and now money is running out.

In a letter this week to Health and Human Services Secretary Kathleen Sebelius, state officials said they were "blindsided" and "disappointed" by a federal proposal they say would shift the risk for cost overruns to states in the waning days of the program.

There was no immediate response from HHS.

Florida governor Rick Scott, one of the biggest critics of President Obama’s health reform efforts, said Wednesday he would do the administration’s bidding and expand the Medicaid program.

But Scott said he was doing the expansion on his own terms: for three years only, while the federal government is footing the entire bill.

“While the federal government is committed to paying 100 percent of the cost of new people in Medicaid, I cannot, in good conscience, deny the uninsured access to care,” Scott said in a news conference.

“We will support a three-year expansion of our Medicaid program under the new health care law, as long as the federal government meets their commitment to pay 100 percent of the cost during this time. This legislation would sunset after three years and need to be reauthorized.”

Scott denied he was giving in to the administration. “It is not a white flag of surrender to government-run health care,” he said.

The 2010 Affordable Care Act was designed to transform health care in the United States, which most experts agree currently costs too much and leaves far too many people without health insurance. It was meant to provide more care to people who can’t buy insurance by forcing states to expand Medicaid.

The hope was to add about 16 million of the poorest people to the rolls -- about half of those who need health insurance. But after a series of challenges to the law, the U.S. Supreme Court ruled in June that the Medicaid expansion requirement went too far. While most of the Affordable Care Act was constitutional, the court ruled, the federal government could not force states to offer Medicaid to more people.

The Congressional Budget Office projects that 12 million people will become newly eligible for Medicaid in the states that choose to expand their offerings by 2022. The law required states to extend Medicaid to people earning up to 133 percent of the federal poverty level, or about $14,800 for single people and $31,000 for a family of four.

Many Republican governors immediately said they wouldn’t expand Medicaid.

Texas governor Rick Perry turned down $76 billion in federal matching funds that would have helped pay to do it over the first five years. “We’re just not going to be a part of … socializing health care in the state of Texas,” Perry told reporters in July.

South Carolina’s Nikki Haley said expanding Medicaid would bring people out who were already qualified -- and she said that her state would go broke taking care of them, even if the federal government paid the bill for those who would newly qualify. In addition, states will have to start paying a very small percentage in 2017.

But health care experts predicted that many red states would not turn away free money from the federal government.

Arizona governor Jan Brewer said her state would expand Medicaid to about 300,000 residents in her state of the state address last month. Michigan governor Rick Snyder made his announcement Feb. 6: His state will add about 320,000 people to the joint state-federal health insurance plan for the low-income.

“I am forced to accept it as today’s reality and I have decided to expand Nevada’s Medicaid coverage,” Nevada governor Brian Sandoval, another Republican,  said in December.

Republican-leaning holdouts include Alabama, Louisiana, Idaho, Mississippi, South Carolina, Maine and 12 others.

Scott said he wasn’t happy, but said he was facing reality.

“There are no perfect options. Our options are either having Floridians pay to fund this program in other states while denying health care to our citizens or using federal funding to help some of the poorest in our state with the Medicaid program as we explore other health care reforms,” he said.

Left-leaning groups applauded.

“Now about 613,000 Florida women stand to gain the security of quality health coverage and the ability to get the care they need, when they need it, without facing huge medical bills,” said Judy Waxman of the National Women’s Law Center.

“Combined with other reforms in the Affordable Care Act, this expansion would reduce the percentage of uninsured women in Florida from 25.3 percent to 5.8 percent.”

Scott says he’s not against health reform, he just doesn’t like the approach taken in the 2010 health reform law.

“Before I ever dreamed of standing here today as Governor of this great state, I was a strong advocate for better ways to improve health care than the government-run approach taken in the President’s health care law,” he added.

“I believe in a different approach. But, regardless of what I -- or anyone else -- believes, a Supreme Court decision and a presidential election made the President’s health care mandates the law of the land.”

Scott says he will still refuse to set up a state health insurance exchange, leaving the federal government to run it.

Related stories:

• Who falls through the Medicaid cracks
• State elections determine health reform's future
• Fewer may get health insurance under law, CBO says 

Eric Kayne / for NBC News

Brandi DeFrank's son Gabriel, 3 months old, is covered under Medicaid, but the program's coverage for the Texas mom herself ended when she gave birth.

As Mitt Romney and President Barack Obama pack in some last-minute campaigning before Tuesday’s election, polls show voters are split just about down the middle on who they prefer: Romney, who has promised to do everything he can do repeal the 2010 health reform law, and Obama, who says its benefits are just beginning to take hold.

But while the presidential race gets most of the attention, the choices voters make to fill governor’s mansions and state legislatures may have just as big an effect on what kind of health coverage they will have in coming years.

That’s in part because the Affordable Care Act sets it up that way, but even more so because the Supreme Court says it’s up to states to decide whether and how to expand the Medicaid health insurance plan for the poor.

“One thing the voters should be aware of is what are their governors are going to be doing. Will more people have access to Medicaid or access to a state-run exchange?” says John Poelman of healthcare consulting firm Leavitt Partners and a former health policy analyst at the Department of Health and Human Services.

Two states at the two extremes of health care coverage are Texas, with a free-market, bare-bones approach, and Vermont, which is unabashedly going for a European-style, government-supported system.

Brandi DeFrank is one of the 6.3 million people in Texas who lack health insurance. That's a quarter of the state's population and the highest percentage of uninsured people in the country.

Like millions of women across the country, DeFrank, 20, was fully covered under Medicaid, the state-federal health insurance plan for low-income people, while she was pregnant. The birth of her 3-month-old son, Gabriel, was also covered, but after that, her own coverage ended. The baby remains on Medicaid -- all states make some provision for children whose parents lack insurance -- but now DeFrank is on her own and gambling that she won’t get sick.

Under federal law, DeFrank could have been covered under her parents’ health insurance. But when she moved out at 18, her father said she had to learn to be an adult.

“He took me off his insurance,” said DeFrank as she cradled Gabriel in a cheerful playroom at Legacy Community Health Services, a non-profit health clinic in southwest Houston where Gabriel gets care. Her husband, who is working as an intern at a medical clinic, is also not covered, says DeFrank, who is about to begin applying to nursing school.

“I didn’t really think about Medicaid or anything. You’re just thinking about college,” she added. “I saved all my money for books.”

'We're not going to be a part of socializing health care'
Texas governor Rick Perry, a Republican, has said he won’t expand Medicaid to cover people like DeFrank, and the Republican-dominated Texas legislature backed him in turning down $76 billion in federal matching funds that would have helped pay to do it over the first five years.

“We’re just not going to be a part of … socializing health care in the state of Texas,” Perry told reporters in July.

But in Vermont, Gov. Peter Shumlin, a Democrat, and the current legislature are pushing hard for a single-payer system that they say will give them the leverage to lower prices and provide better care for everyone in the state. But they’re not there yet and the election will decide if the state will continue to go in that direction, or whether it will be forced to roll back.

The state’s current continuum of programs asks patients to pay at least a minimum premium if they can. They include Catamount Health, a state plan providing subsidies for some people, along with Blue Cross Blue Shield of Vermont; Vermont Health Access Plan, which provides insurance for people who have gone without for a year or more; Dr. Dynasaur; Medicaid, and pharmacy assistance and premium assistance programs.

On Tuesday, residents will go to the polls to decide whether to keep pushing more, towards government-directed health care plan that covers everyone, paid for by taxes.

That’s what Anna Gebhardt would like to see happen. Even though Vermont offers more coverage options for low-income families than some other states, she and her husband, Oliver, don’t have insurance. Their jobs don’t offer coverage, they can’t afford to buy a private policy and, since Oliver got a raise a few months ago at his job as an audio engineer, they earn too much money to qualify for Medicaid. Their children, Leviah, 6, and Immanuel, 13, are covered under the state’s Dr. Dynasaur program, which offers low-cost coverage for kids, but the family struggles to make the payments for it.

Two weeks ago, Gebhardt, a 33-year-old preschool teacher, was sitting nervously in a Burlington, Vt., emergency room after Leviah fell down at school. When the girl was still crying hours later, her mother took her in. It wasn’t an easy decision. Gebhardt was not entirely sure she was paid up on Anna’s health insurance premium under the Dr. Dynasaur program.

“My fingers were crossed and I was thinking ‘Did I pay the bill last month?’” said Gebhardt. “Two other people had to come over and help make sure we were covered before we could even see a doctor. This gives you a lot of anxiety when you have a child who is crying and in pain,” Gebhardt said. Luckily, she had paid and Leviah was just just fine.

DeFrank and Gebhardt are just the type of people that Democrats want to reach with expanded health care, subsidized by the government if needed. And they’re just the type of people that Republicans say could buy their own insurance if the government would just let the free market take over.

The 2010 Affordable Care Act was designed to transform health care in the United States, which most experts agree currently costs too much and leaves far too many people without health insurance. The Affordable Care Act calls for states to set up insurance exchanges, where people who don’t have health insurance through an employer or through government programs can go and buy a plan -- with government subsidies, if they need them.

It also was meant to provide more care to people who can’t buy insurance by forcing states to expand Medicaid. The hope was to add about 16 million of the poorest people to the rolls -- about half of those who need health insurance. But after a series of challenges to the law, the U.S. Supreme Court ruled in June that the Medicaid expansion requirement went too far. While most of the Affordable Care Act was constitutional, the court ruled, the federal government could not force states to offer Medicaid to more people.

'They can disrupt implementation of the law'
So now two of the biggest provisions of the law -- offering Medicaid to more people and setting up the health exchanges -- are in the hands of state officials.

“They can disrupt implementation of the law. Leadership can either be aggressively moving it forward or impeding it,” Poelman says.

The Obama administration is offering to pay the full cost of expanding Medicaid at first, but lawmakers in states like Texas say they can barely afford Medicaid now, let alone when they’ll have to start kicking in 7 percent for all those extra people in 2019.

This frustrates Garnet Coleman, a Democrat in the Texas legislature who represents much of Houston’s poor downtown. Coleman says not only would expanding Medicaid save money in the long run, by getting people treated earlier, it would create much-needed jobs. “Health care is a growth sector,” Coleman says. It will create “beaucoup jobs -- good jobs, as your mama would say.” Jobs that people can get with two-year degrees. “This is just a boost in the arm to the state of Texas,” he says.

Coleman is delighted that Perry and the legislature are balking on setting up an exchange for Texas and looks forward to seeing what the federal government will do instead. The 2010 health reform law says that if states don’t set up their own exchanges by 2014, HHS will do it for them.

Different paths to the same goal
It’s not that Democrats want health care and Republicans don’t. Both sides agree in principle that it’s better for everyone to have health insurance of some kind.  It’s cheaper to treat disease or injuries early, and best to prevent disease in the first place. People are more likely to get vaccinated and to take medications such as blood pressure drugs if they’re seeing a doctor regularly.

The Obama administration says the way to get there is with subsidies and government oversight, with a healthy marketplace allowing private health insurers to offer more to those who can pay -- and strict regulation to make sure insurance companies don’t cherry-pick the healthiest customers or dump patients just when they need insurance the most.

Republicans argue that freeing up the marketplace would do that more efficiently. They say that government regulations make it impossible for insurers and health care providers to compete enough to bring costs down.

“No one says it’s better to leave people out,” says Joel Ario, former director of health insurance exchanges at HHS, who is now at law and consulting firm Manatt Phelps & Phillips. “It is just a question of what we can afford or not afford.” It’s also a question of who can best make those decisions – states or the federal government.

“With exchanges, the question is whether the federal government should have a heavy hand in making them work,” Ario added.

In Texas, polls suggest the Republicans will dominate. This likely means Texas will continue to offer a bare minimum of health care and will let the federal government set up its health exchanges.

“There are states referred to as ‘Hell, no states’,” said David Smith, an analyst at Leavitt, the healthcare consulting firm. “A lot of those states don’t necessarily have governors who are up for election.” In those states, voters have to decide whether to help governors by electing members of the same party to the state house.

In Vermont, Shumlin’s Republican opponent, Randy Brock, says single-payer health care is too expensive. Vermont’s legislature will take up the question of how to pay for it in January, with options including a capital gains tax or a tax on employers.

Where other states stand
Republican governors like Iowa’s Terry Branstad, Arizona's Jan Brewer, Sam Brownback of Kansas, Louisiana’s Bobby Jindal, Nebraska’s Dave Heineman, Nikki Haley of South Carolina and Scott Walker of Wisconsin say they have no intention of expanding Medicaid. Florida’s Rick Scott says he won’t expand Medicaid even though his state has the second-highest rate of uninsured adults, after Texas.

Leavitt’s team predicts the majority of state governors -- at least 30 -- will be Republican after the election. Eleven states will be electing governors, and eight of them have Democrats in office now.

States that are safe for Democrats include Maryland, where Gov. Martin O'Malley was one of the first governors to move on health reform. Oregon governor John Kitzhaber also makes health reform a central policy.

Next door in Washington state, health care is playing a big role in making the race tight, with Democrat Jay Inslee, an eight-term congressman from Seattle, battling the Republican state attorney general Rob McKenna. Inslee supported the health law in Congress; McKenna isn’t against expansion but he thinks Medicaid patients should share some of the costs. 

In Indiana’s race, Republican congressman Mike Pence has said he wouldn’t set up a state insurance exchange. His Democratic opponent John Gregg hasn’t endorsed the health reform law, either, but has met with current governor Mitch Daniels about how Indiana should move forward on building a health insurance exchange.

Alabama, Florida, Montana and Wyoming have ballot measures asking residents whether they want to block the mandate requiring people to get health insurance. Missouri voters are being asked to decide whether to allow the governor to establish health insurance exchanges.

While they wait to see what happens, Gebhardt and her husband, Oliver, are gambling that they won’t get sick and need medical care.

“We are constantly at the whim of decisions being made by people who don’t depend on those services and don’t realize how their decisions affect people,” Gebhardt said. “We are constantly in limbo. We could create a system where efficiency works for the people and for the budget. That is where Vermont can lead the way.”

Related stories:

• Falling through the cracks if states don't expand Medicaid
• U.S. health care: It's officially a mess, institute says

Ami Vitale for NBC News

Derek Anderson, sitting next to his wife Erica, takes medication every day following a bone marrow transplant to treat his leukemia. He's been on Medicare since he lost his job and his insurance. The couple hopes to qualify for Medicaid in 2014.

Derek Anderson never imagined he'd wind up on welfare. At 36, he has a college degree, a solid background in sales and three kids under the age of 7. He's also recovering from leukemia and since he lost his job and his employer-sponsored insurance, he’s been on Medicare, the federal health insurance plan for the disabled and elderly.

Anderson, who now relies on Social Security disability payments for income while he tries to get back on his feet, worries about whether he can get a job with health insurance. If he starts working, he'll lose eligibility for Social Security and Medicare -- but he and his wife, Erica, would likely be eligible for Medicaid if his home state, Montana, expands it as called for under the 2010 health reform law and offers it to low-income adults. However, their future is now unclear after the Supreme Court said states can opt out of the expansion.

He says he's worked hard to pay all his medical bills and says opponents of health care reform have overlooked people like him, who are not seeking a free ride. “I have a college degree. I had a job. When something like this hits you, [people like me] have no idea how the welfare system works because they never needed it,” Anderson said in a telephone interview.

Anderson was working in copier sales when he was diagnosed with leukemia in 2008. It quickly became clear he needed a bone marrow transplant -- a grueling procedure that requires chemotherapy to kill off a patient’s own bone marrow and then an infusion of new bone marrow. He estimates it cost his employer’s private insurance plan $500,000 for the 2009 transplant, and he’s run up tens of thousands in charges since then for care that includes strong immune-supressing drugs that he still takes while the new bone marrow slowly takes over.

When Anderson’s grandmother died, he and Erica moved with their three children, now aged 6, 5 and 4, from Seattle to her home in Butte, Mont. He had taken short-term disability at his sales job but he maxed it out and when it became clear he would not be well enough to return to work any time soon, he resigned.

Erica Anderson is winging the summer without health insurance at all, and just hoping she doesn’t get sick. The 28-year-old will be covered when she starts taking college classes again in the fall, but the school insurance plan doesn’t cover family. She worked for a while but quit to take care of her ailing husband and children and to take classes in the hope of getting a better job.

"Getting a job for insurance is a dead end. We don’t want to get stuck in that dead-end cycle,” Erica Anderson says.

The children are covered by "Healthy Montana Kids," the state’s version of the federal-state Children’s Health Insurance Program.

One of the main goals of the 2010 Patient Protection and Affordable Care Act was to extend health insurance starting in 2014 to 32 million people who currently are not covered. A big part of this was to be through expanding Medicaid, the state-federal health insurance plan for the poor.  Most states now use Medicaid to cover pregnant women and children but exclude childless adults, in part because they lack the budget to cover more people.

The law required states to extend Medicaid to people earning up to 133 percent of the federal poverty level, or about $14,800 for single people and $31,000 for a family of four. The federal government calculated this would add at least 16 million people to Medicaid.  

But the Supreme Court ruled in June that the federal government cannot make the states do this. It must be optional. Immediately, several Republican governors said they’d be opting out, including Louisiana’s Bobby Jindal, South Carolina’s Nikki Haley, Rick Scott of Florida and Rick Perry of Texas. Others are on the fence, including Gov. Bob McDonnell of Virginia, the chairman of the Republican Governors Association; Gov. Scott Walker of Wisconsin; and even some Democrats such as Montana Gov. Brian Schweitzer.

The law provides for the federal government to pay for every new Medicaid enrollee added under the extension, but the states will have to start kicking in a small percentage after a few years. Governors of many states say they’ll have to slash education or other programs, or raise taxes, to cover this. Many governors are also worried that people who didn’t know they have been eligible for Medicaid and possibly other state programs will seek it out because of the publicity and outreach that would surround an expansion.

Supporters of reform say that’s no reason for states to balk.

“Just because we do a terrible job of enrolling people doesn’t mean we have an excuse,” said Dr. Stuart Hamilton, founder and Chief Executive Officer of the Eau Claire Cooperative Health Centers in Columbia, S.C., which provide low-cost medical care on a sliding fee scale. “For three years South Carolina is going to get those individuals paid for at 100 percent. So it would cost us absolutely nothing.”

South Carolina state senator Darrell Jackson, a Democrat who is also senior pastor at Bible Way Church of Atlas Road, a megachurch in Columbia, says his state will suffer if Gov. Haley doesn’t expand Medicaid. “When this legislation was crafted, it had states like South Carolina in mind,” Jackson said in a telephone interview. “We have a substantial portion of working people who cannot afford health insurance. They have to make a decision: their mortgage or health insurance, food on the table or health insurance.”

Elise Spigner is one such example. The 58-year-old stay-at-home mother sees herself as a rock for her friends and family, stepping in when someone has a stroke, caring for a disabled son. With her solidly middle-class background – she comes from a prominent South Carolina family – Spigner never thought she would rely on charity for her health care. “I was raised with a silver spoon in my mouth,” she says.

But a divorce in 1996 left her without her husband’s health insurance, and she gets medical care through one of the Eau Claire Cooperative Health Center's clinics. The non-profit’s business plan was supposed to run out in 2014, when the 2010 health reform law takes effect.  “I have been taking care of everybody else for 55 years and not taking care of me,” says Spigner, who is working to finish a nursing degree.

Dean Slade, director of grants and strategic planning at Eau Claire, makes the standard argument for extending government health insurance to as many people as possible – that it will save money in the long run. The Commonwealth Fund, which advocates for health reform, has shown in study after study that Americans spend at least twice as much per capita as the residents of other developed countries on health care, but die sooner and get lower quality care.

Slade argues that this is in no small part because tens of millions of Americans get little or no health care until they are in an acute and costly crisis, such as having a heart attack or stroke. “You have to spend money to save money, but we could significantly reduce the cost of care by just making sure that people got their medicine, that people saw their doctors regularly,” Slade says.

But opponents of the expansion say the country simply cannot afford it. Many Republicans instead support a voucher system that would help more people to buy private health insurance. “A government-run program, and a new government entitlement program — when we can't afford the ones we've got — makes absolutely no sense at a time when we’ve got over $15 trillion of debt,” Louisiana’s Jindal said earlier this month.

Advocates for reform argue that in the end, the public pays the bills when people go without regular health care and wait for an emergency to get care – and they say people struggling to make ends meet are almost certainly going to skimp on health insurance.

Chad Clayton says he’s an example. When an attack of acute pancreatitis hit him in March of last year, Clayton hadn’t yet worked the 90 days needed to qualify for employer-sponsored health insurance at his job as a meat cutter in Portland, Tenn. 

Clayton says he was taken by ambulance to a hospital where he was unconscious for 23 days after that, suffering from blood infections and multiple organ failure. Now 43, Clayton says the hospitals that treated him are likely on the hook for his bills. “My bills are about $500,000.  I can’t pay none of them,” he said. “My first hospital bill was $192,000, not including doctors. I wouldn’t even know where to begin.” Health experts agree hospitals in these cases will pass along its costs in the form of higher bills to paying customers.

Clayton said he applied for Medicare last year but was turned down.

“I think if you have worked your whole life and you have paid into Medicare and you need some temporary aid, you should be able to get it,” he said. “They don’t have no problems taking it out of your check. They sure don’t want to put it back.”

Medicaid coverage now -- and in 2014:

• 33 states only cover parents earning less than the federal poverty level of $18,530 for a family of three in 2011. The other 17 states will only cover parents who earn less than half that. Just 9 states provide full Medicaid benefits to other adults.
• The 2010 health care law asks states to extend this to all adults making 133 percent or less of the federal poverty level, although in reality this will be 138 percent because of wiggle room on income. Kaiser estimates that of 41.2 million adults with health insurance, 52 percent or 21.6 million of them made this much money or less.
• Adults making between 100 percent and 138 percent of the poverty level can get federal subsidies to buy private health insurance on new health insurance exchanges that are supposed to be up and running in each state by 2014.
• But the poorest poor – those making less than the poverty level – will not be eligible for subsidies. The health reform law presumed these people would be covered by Medicaid but they will not be if states don’t expand their programs.
  Source: Kaiser Health News

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Only a quarter of Americans infected with the AIDS virus are getting effective treatment, according to a U.S. government report released Friday -- and the youngest patients are the worst off.  The numbers could worsen if states don’t broaden health care as called for under the 2010 health reform law, scientists worry.

It’s the first comprehensive look by the Centers for Disease Control and Prevention at who is getting effective care, and it doesn’t paint a promising picture. The findings raise even more alarm bells as study after study presented at the International AIDS Conference in Washington this week show that treatment can help stop the spread of HIV.

“The majority of people living with HIV in the United States are not on antiretroviral treatment, not in stable care,” Dr. Kenneth Mayer of The Fenway Institute and Harvard Medical School in Boston told a news conference. “They need to be in care first and then able to get treatment.”

The study finds that just over a third of  HIV patients have steady care -- 34 percent  of African-Americans, 37 percent of Latinos and 38 percent of whites.

Younger patients are the least likely to be getting the cocktails of drugs that can keep them healthy and help keep them from infecting others. Just 15 percent of those aged 25-34 had the virus suppressed to desired levels, compared to 36 percent of those aged 55-64. Only 22 percent of young adults were even getting HIV drugs to treat their infection, the CDC found.

There’s no cure for the human immunodeficiency virus that causes AIDS and no vaccine. HIV has killed 25 million since it first started spreading globally in the early 1980s, and more than 33 million people are infected worldwide. About 1.1 million people in the United States have HIV, and the CDC estimates that 20 percent of them don’t even know it.

“We have to continue to raise the alarm,” CDC’s top AIDS official, Dr. Kevin Fenton, said in an interview. “We have to find that sense of outrage.”

The same factors are driving high transmission and poor treatment rates among some U.S. groups: poverty, a lack of access to medical care, and a lack of education about what causes HIV and what people can do about it. Policymakers need to understand that treating people with HIV saves money, Fenton said. 

“What we now know is that treating HIV is cost-effective. For every dollar spent, you save $2,” Fenton said.

Fenton said the U.S. should pull out the stops on providing condoms, counseling, testing and treatment.

“We need to ensure that states have policies that support routine HIV testing,” Fenton said. “Clearly, this is going to be more challenging in some states than in others.”

Top AIDS experts in the U.S. say no matter what people may think about the moral implications of some of the behavior that leads to HIV infection, it will benefit everyone to get people tested, treated and counseled about controlling their infection.

“Every state really must enact the Affordable Care Act,” said Dr. Judith Aberg, president of the HIV Medicine Association and an AIDS expert at New York University. “States need to fund HIV treatment and prevention. We need to continue this fight.”

Governors of several states have said they will not expand Medicaid, required by the health care law, because they cannot afford it. The U.S. Supreme Court ruled last month that states can decide whether to abide by that provision. States refusing expansion now include Texas, Florida, South Carolina and Louisiana. Medicaid, the state-federal health insurance plan for the poor, currently does not cover most low-income adults with HIV. AIDS activists say it’s essential to controlling the epidemic to get coverage for young adults with HIV, and at risk for HIV.

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