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| Supreme court ruling: Medicaid expansion becomes political football | Supreme court ruling: Medicaid expansion becomes political football |
| (4 months later) | |
| While the supreme court's decision to uphold the Obama administration's individual mandate took the headlines, the court's decision to allow states to opt out of a key part of the law may turn the healthcare of millions of uninsured Americans into political football. | While the supreme court's decision to uphold the Obama administration's individual mandate took the headlines, the court's decision to allow states to opt out of a key part of the law may turn the healthcare of millions of uninsured Americans into political football. |
| The package of reforms included a wide expansion to the federal Medicaid programme designed to give America's poor access to healthcare – but a majority of justices ruled that the government couldn't force states to take part. | The package of reforms included a wide expansion to the federal Medicaid programme designed to give America's poor access to healthcare – but a majority of justices ruled that the government couldn't force states to take part. |
| As a result, Republican politicians may use their new-found opt out to undermine the Affordable Care Act (ACA) reforms – and blow a big hole in its attempts to cover uninsured Americans – even if it costs their own states billions of dollars in lost federal aid. | As a result, Republican politicians may use their new-found opt out to undermine the Affordable Care Act (ACA) reforms – and blow a big hole in its attempts to cover uninsured Americans – even if it costs their own states billions of dollars in lost federal aid. |
| In particular, Florida's Republican leadership – which led the charge against the law all the way to the supreme court – may repeat its recent history of turning down federal stimulus funding by rejecting the Medicaid expansion. | In particular, Florida's Republican leadership – which led the charge against the law all the way to the supreme court – may repeat its recent history of turning down federal stimulus funding by rejecting the Medicaid expansion. |
| "Of course, a state would have to have a pathologically strong attachment to political principle to walk away from hundreds of millions of federal dollars and leave thousands or hundreds of thousands of its citizens uninsured," commented Timothy Jost, a law professor and healthcare expert at the Washington & Lee University, in a blogpost. | "Of course, a state would have to have a pathologically strong attachment to political principle to walk away from hundreds of millions of federal dollars and leave thousands or hundreds of thousands of its citizens uninsured," commented Timothy Jost, a law professor and healthcare expert at the Washington & Lee University, in a blogpost. |
| One of the first to react to the decision was Nevada's Republican governor Brian Sandoval, who told a local television station: "As I sit here today, it wouldn't be my intention to opt in." In a later statement Sandoval cited "serious financial implications" of the expansion and called on Congress to "ease the serious burdens it places on the states". | One of the first to react to the decision was Nevada's Republican governor Brian Sandoval, who told a local television station: "As I sit here today, it wouldn't be my intention to opt in." In a later statement Sandoval cited "serious financial implications" of the expansion and called on Congress to "ease the serious burdens it places on the states". |
| According to the Congressional Budget Office, the revamped Medicaid programme is a central part of Obama's healthcare reforms, and is projected to account for around half of the insurance expansion. A boycott by some of America's biggest states could put a dent in those projections. | According to the Congressional Budget Office, the revamped Medicaid programme is a central part of Obama's healthcare reforms, and is projected to account for around half of the insurance expansion. A boycott by some of America's biggest states could put a dent in those projections. |
| Research by the Kaiser Commission on Medicaid and the Uninsured estimates that in Florida alone, the Medicaid expansion would add 950,000 uninsured residents to the state's Medicaid rolls by 2019. And while the federal government would pick up the vast majority of the tab, some $20bn, the expansion would still cost the state of Florida $1.2bn by 2019. | Research by the Kaiser Commission on Medicaid and the Uninsured estimates that in Florida alone, the Medicaid expansion would add 950,000 uninsured residents to the state's Medicaid rolls by 2019. And while the federal government would pick up the vast majority of the tab, some $20bn, the expansion would still cost the state of Florida $1.2bn by 2019. |
| "Cash-strapped states will almost certainly consider this option since they will ultimately be on the hook for financing at least a portion of this expansion," wrote Stanford health economist Jay Bhattacharya. | "Cash-strapped states will almost certainly consider this option since they will ultimately be on the hook for financing at least a portion of this expansion," wrote Stanford health economist Jay Bhattacharya. |
| "If enough states decide to deny the Medicaid expansion, this may substantially reduce the ability of ACA to expand insurance coverage." | "If enough states decide to deny the Medicaid expansion, this may substantially reduce the ability of ACA to expand insurance coverage." |
| Already, Florida's Republican governor Rick Scott and state GOP leaders have claimed that the state's taxpayers can't afford any expansion in the programme. | Already, Florida's Republican governor Rick Scott and state GOP leaders have claimed that the state's taxpayers can't afford any expansion in the programme. |
| In Texas, the situation is even more dramatic, with more than one in four Texans lacking health insurance. The Medicaid expansion could extend coverage to 1.8 million people, at a cost to the state of $2.6bn by 2019 – or more than $500m a year. | In Texas, the situation is even more dramatic, with more than one in four Texans lacking health insurance. The Medicaid expansion could extend coverage to 1.8 million people, at a cost to the state of $2.6bn by 2019 – or more than $500m a year. |
| If Texas and Florida – along with a hard-core of other GOP-dominated states, such as South Carolina, Georgia, Wisconsin and Alabama – decided to opt out of the expansion, some four million people could be denied coverage. | If Texas and Florida – along with a hard-core of other GOP-dominated states, such as South Carolina, Georgia, Wisconsin and Alabama – decided to opt out of the expansion, some four million people could be denied coverage. |
| But John Culhane, director of the Health Law Institute at Widener University, said that he doubts many states will follow that route because it will not be in their financial interests. | But John Culhane, director of the Health Law Institute at Widener University, said that he doubts many states will follow that route because it will not be in their financial interests. |
| Under the legislation, the federal governments pays the entire cost of the expansion of Medicaid for the first few years. That eventually drops to around 90%. And while the states will never have to pick up more than a fraction of the real costs, they currently often have to cover the expense of the uninsured who walk into the emergency rooms of public hospitals and receive coverage. | Under the legislation, the federal governments pays the entire cost of the expansion of Medicaid for the first few years. That eventually drops to around 90%. And while the states will never have to pick up more than a fraction of the real costs, they currently often have to cover the expense of the uninsured who walk into the emergency rooms of public hospitals and receive coverage. |
| "The states would be crazy in my opinion not to take it," said Culhane. "If the Feds are giving you all of this money why would you turn this down? You would have deeply political reasons and really hate this legislation. Maybe one or two deep southern states might do this but I would be willing to bet that most will not." | "The states would be crazy in my opinion not to take it," said Culhane. "If the Feds are giving you all of this money why would you turn this down? You would have deeply political reasons and really hate this legislation. Maybe one or two deep southern states might do this but I would be willing to bet that most will not." |
| It may be that a handful of states including Florida may prefer to indulge in political grandstanding during the election season – and quietly accept the funding for expansion once the subject dies down in the event of Obama's re-election. | It may be that a handful of states including Florida may prefer to indulge in political grandstanding during the election season – and quietly accept the funding for expansion once the subject dies down in the event of Obama's re-election. |
| In 2009 and 2010 several Republican governors pointedly rejected federal stimulus funds – Florida turned down a $2bn rail scheme – with a number later overruled by state legislators who preferred to see their constituents receive the benefits. | In 2009 and 2010 several Republican governors pointedly rejected federal stimulus funds – Florida turned down a $2bn rail scheme – with a number later overruled by state legislators who preferred to see their constituents receive the benefits. |
| The supreme court's decision came on a 7-2 vote that held that a clause withdrawing federal funding for Medicaid programmes in states that do not expand coverage to anyone under 65 years old living below 133% of the poverty line was unconstitutionally coercive. | The supreme court's decision came on a 7-2 vote that held that a clause withdrawing federal funding for Medicaid programmes in states that do not expand coverage to anyone under 65 years old living below 133% of the poverty line was unconstitutionally coercive. |
| The court ruled that the government is entitled to use the carrot of offering additional funds to encourage co-operation, and can require it if states accept the new monies, but not the stick of threatening to withdraw existing funds. | The court ruled that the government is entitled to use the carrot of offering additional funds to encourage co-operation, and can require it if states accept the new monies, but not the stick of threatening to withdraw existing funds. |
| "Nothing in our opinion precludes Congress from offering funds under the Affordable Care Act to expand the availability of healthcare, and requiring that States accepting such funds comply with the conditions on their use. What Congress is not free to do is to penalize states that choose not to participate in that new program by taking away their existing Medicaid funding," the ruling said. | "Nothing in our opinion precludes Congress from offering funds under the Affordable Care Act to expand the availability of healthcare, and requiring that States accepting such funds comply with the conditions on their use. What Congress is not free to do is to penalize states that choose not to participate in that new program by taking away their existing Medicaid funding," the ruling said. |
| The justices said that the states were threatened with "economic dragooning" if they declined to go along with what amounts to a dramatic expansion of Medicaid from covering specific categories of people, such as the disabled, to providing much broader health insurance. | The justices said that the states were threatened with "economic dragooning" if they declined to go along with what amounts to a dramatic expansion of Medicaid from covering specific categories of people, such as the disabled, to providing much broader health insurance. |
| "Under the Affordable Care Act, Medicaid is transformed into a program to meet the healthcare needs of the entire non-elderly population with income below 133% of the poverty level. It is no longer a program to care for the neediest among us, but rather an element of a comprehensive national plan to provide universal health insurance coverage. Indeed, the manner in which the expansion is structured indicates that while Congress may have styled the expansion a mere alteration of existing Medicaid, it recognized it was enlisting the states in a new healthcare program," the ruling said. | "Under the Affordable Care Act, Medicaid is transformed into a program to meet the healthcare needs of the entire non-elderly population with income below 133% of the poverty level. It is no longer a program to care for the neediest among us, but rather an element of a comprehensive national plan to provide universal health insurance coverage. Indeed, the manner in which the expansion is structured indicates that while Congress may have styled the expansion a mere alteration of existing Medicaid, it recognized it was enlisting the states in a new healthcare program," the ruling said. |
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