Still Worries over the Affordable Care Act

Those who supported the Affordable Care Act, often referred to derisively by its opponents as “Obamacare”, are rejoicing over the recent Supreme Court decision to keep it largely intact.  But there are some who are worried about whether the future Medicaid expansion that is an important part of this law was fatally weakened by a part of this decision.

One of the fundamental purposes of the ACA is to expand health insurance coverage to as many of the estimated 50 million uninsured Americans as possible. Many of the uninsured earn not much more than what the government has established as the poverty line.

In 2010, in the United States, the poverty threshold for one person under 65 was US$11,344 (annual income); the threshold for a family group of four, including two children, was US$22,133.  According to the U.S. Census Bureau data released on September 13, 2011, the nation's poverty rate rose to 15.1 percent in 2010.

Since Medicaid covers people at or below the poverty line, those who are even slightly above the poverty line are now ineligible for coverage. But at the same time, they still do not make enough to afford health insurance – especially those with preexisting conditions. So one of the important provisions of the ACA was to expand Medicaid to those making up to 133% of the poverty line.

Although this is a federal program, it is up to the individual states to decide whether to accept the money from the Feds and implement this expansion.  Part of the ACA included some ‘gentle persuasion’ saying that if an individual state refused the expanded Medicare, it would lose all of its existing Medicare funding.

But this part of the law was struck down by the Court.

In a 7-to-2 decision, with Justices Elena Kagan and Stephen G. Breyer joining the five conservatives, the court ruled that the new provisions of the act giving coverage to all Americans under 133 percent of the poverty level constituted not an expansion of the program but actually a new Medicaid program. Threatening states that did not adopt this provision with termination of all their matching federal Medicaid money, the court said, constituted “a shift in kind, not merely degree.” The court viewed this Medicaid provision as coercion — “withholding of ‘existing Medicaid funds’ is ‘a gun to the head’ ” — that would force states to acquiesce.

I think most fair-minded people would agree that this was overly coercive.  But in striking it down, the result went to the other extreme which gives the federal government almost no leverage over the individual states to comply.

This has given Republican governors in several states the opportunity to publicly renounce the law by saying that they will not accept the money for this expansion.

Republican officials in more than a half-dozen states said they opposed expanding Medicaid or had serious doubts about it, even though the federal government would pick up all the costs in the first few years and at least 90 percent of the expenses after that. 

In writing the law, Congress assumed that the poorest uninsured people would gain coverage through Medicaid, while many people with higher incomes would receive federal subsidies to buy private insurance. Now, poor people who live in a state that refuses to expand its Medicaid program will find themselves in a predicament, unable to obtain either Medicaid or subsidies.

That really sucks!

It’s one thing for ideologues to spout off their views on conservatism and limited government for others in their party to admire.  But is this worth putting human lives in peril for the sake of little more than political posturing?

This appears to be a game of chicken being waged by these governors.  If they can convince their citizens that sticking to conservative principles is more important than insuring as many people as possible, the governors win and those who must go needlessly without health insurance lose.  On the other hand, if enough people catch on to what’s being done to them by their leaders, they will have to back down from their position while risking the wrath of their electorate when they go to the ballot box.

The best guess is that the governors will eventually have to back down.  After all, the deal from the Feds is simply too good for them to turn down.  But the question remains, what kind of person would inflict all of this on others in the first place?