My emotions after the Supreme Court’s ruling on the Affordable Care Act last week went through various stages: confusion (thanks, CNN), shock and finally sheer joy. It was a complete surprise to have the highest court uphold the entire law, including the individual mandate. Liberals rightly celebrated the ruling as a historic step toward ensuring a better quality of life for all Americans.
But in the jubilation hangover, some more sober analysis has taken its place. One important aspect of the Court’s decision gives no reason to celebrate: the ruling that the federal government can’t withdraw all Medicaid funds from governors who refuse to expand Medicaid rolls in their states, essentially making it possible for them to opt out. The Medicaid expansion is meant to give coverage to about 17 million Americans by 2019, accounting for almost half of the 32 million people the bill promised to insure. Yet as Sarah Kliff reported, if states opt out of expanding Medicaid, it could leave some of the poorest Americans stuck in a no-man’s land in which they don’t qualify for Medicaid but also don’t qualify for subsidies to buy insurance. Beyond literally being a matter of life or death for many uninsured Americans, it’s also an economic issue: the White House calculated that expanding the number of Americans with insurance would increase economic well-being by about $100 billion a year, or about two-thirds of a percent of GDP.
It seems foolhardy for governors to reject what is basically free money to help more people in their own states gain health insurance. Josh Barro wrote just after the ruling that while the White House’s stick was taken away, its carrot—the federal government’s picking up 100 percent of the states’ Medicaid expansion tab for the early years, gradually declining to 90 percent after that—would be enough to incite states to participate. And they stand to see other economic benefits. States that already provide coverage and care to people living at 133 percent of the poverty line would no longer shoulder those costs, saving them millions. Even for those that don’t offer such coverage, the bill stands to save all states money by getting rid of the “hidden tax” they pay in higher insurance premiums that account for the cost of covering the uninsured, also potentially saving millions.