How is Indiana going to ensure health insurance to the "working poor?"

State Rep. Ed Clere, the New Albany Republican who chairs the House Public Health Committee, defines this estimated pool of 400,000 Hoosiers like this: "These are people who are doing exactly what Republicans want them to do. The father works in a factory. The mother is a retail clerk." They are more than likely to be Republicans.

Together, they might bring in $40,000 to $50,000 a year. But the factory and the retail store don't provide health insurance, and even if they do, in many cases it's a flimsy policy.

"If they have a major health issue, they face a financial disaster," Clere said.

Or as Dr. Aaron E. Carroll of the Indiana University School of Medicine, told the committee, "The choice for many isn't between Medicaid and some private insurance. The choice is between Medicaid and nothing."

Now, if you're poor and below the poverty level, you're covered by existing Medicaid. If you're rich or in the middle to upper levels of the middle class, your employer provides or you buy a health insurance policy that could cost your family between $10,000 and $20,000 a year.

Now, there is no question: Hoosiers don't like "Obamacare."

But here's the indisputable reality: The Affordable Care Act became a long-term reality when President Obama defeated Mitt Romney last November. It's the law of the land.

Indiana must now make decisions on how it will participate and in the next weeks and months, decisions that could impact 400,000 working Hoosiers with billions of dollars of implications will be made by Gov. Mike Pence and the Republican-dominated Indiana General Assembly.

The Medicaid debate came as Gov. Mike Pence - parting ways with GOP governors in Michigan and Ohio - issued an ultimatum to Health and Human Services Secretary Kathleel Sebelius this past week. Pence has ruled out expanding Medicaid under the federal health care law unless Indiana gets approval to use its Healthy Indiana Plan savings accounts for the expansion.

"It was important to me that we do fully fund Medicaid, but we did not fund a Medicaid expansion, nor do I think that under the current framework for Medicaid that it would be advisable for Indiana to do that," Pence said.

He reiterated that stance, with his office saying the governor "flatly refused to expand the traditional Medicaid program in Indiana."

In a letter to Sebelius, Pence requested federal approval to use the Healthy Indiana Program to serve an expanded Medicaid population.

"Medicaid is broken," said Pence. "In Indiana, an expansion of traditional Medicaid under the Affordable Care Act would cost our taxpayers upwards of $2 billion over the next seven years."

Bills in the Indiana House and Senate advanced that pave the way for HIP to be the framework of services, though no one can say what those costs will be.

The Healthy Indiana Program currently provides health coverage for about 40,000 Hoosiers, though there are another 46,000 people on the waiting list. So with the governor ruling out a Medicaid expansion, the question is, what happens to the 350,000 to 400,000 "working poor" Hoosiers?

Clere cited the innovative Indiana health care programs - Hoosier Healthwise in 1995 and the Healthy Indiana Plan in 2008. He said HB1591, which would expand Medicaid, "takes the lessons of existing programs" and operates in a way that is "predictable and respectful of the Hoosier taxpayer." He explained his proposal would reflect "Hoosier values" while ensuring that "everyone has skin in the game."

The decisions coming in the next week and months come with billions of dollars at stake. The federal government will cover upwards of 95 percent of the Medicaid expansion until 2020, and 90 percent thereafter. If Indiana declines, it could cost the state billions of dollars.

So the decisions at the Indiana Statehouse made between now and April will impact scores of hardworking and vulnerable Hoosiers for years to come. The flow of these federal dollars could bring about 30,000 jobs as hospitals expand.

The question we all must ask is, what happens here to the working poor?

- Brian Howey publishes online at www.howeypolitics.com. Find him on Twitter @hwypol.