Supreme Court Says ‘Yes’ to Everyone but the Poor?

Image via the Architect of the Capitol/

Back in March, ahead of the Supreme Court’s decision on the Patient Protection and Affordable Care Act, I wondered what might happen to the Medicaid expansion. The question before the court in Florida v. Health and Human Services was whether the federal government could require states to expand their Medicaid eligibility and whether, if states refused, the feds could withhold all of their Medicaid funds.

The answer from the court was that the federal government could neither force states to expand their Medicaid eligibility to 133% of the federal poverty line — $25,389 for a family of three in 2012 — nor could they withhold states’ entire Medicaid share for refusing the expansion.

At the moment, Medicaid eligibility is quite limited. A common misconception is that Medicaid covers all “poor” people. In reality, 26 states provide ZERO Medicaid coverage to childless adults, regardless of income. In other words: single adults in Texas, Nebraska, Pennsylvania, Illinois, and 22 other states could live in abject poverty and remain unqualified for medical assistance. In 13 other states, a childless adult can receive some limited, Medicaid-like benefits. For example, Maryland offers the Primary Adult care program, which provides coverage to adults earning 116% of the federal poverty line, but the program does not cover any inpatient or hospital-based care.

In 33 states, Medicaid eligibility for parents is limited to less than 100% of federal poverty. In 17 of the 33, eligibility is limited to less than half of poverty.

Also at the moment: States pay a share for Medicaid, ranging from half of the costs in wealthier states like Maryland to just over a quarter in poorer states like Mississippi. Under health reform, the federal government would cover 100% of the costs of new enrollees in the initial years; by 2020, the feds would pay 90% of costs. Considering that even poor states have to pay a quarter of costs today, 10% seems like an amazing deal, right?

Sadly, it appears that some states will opt-out of the Medicaid expansion, amazing deal or not.

Texas, with 2.5 million uninsured and the highest rate of child uninsurance in the nation, and Florida, with 1.8 million uninsured, look likely to refuse. Iowa’s Governor Branstad has said he’s not interested. Thus far, 15 states look like they’ll walk away from the additional funds. Interested in your state? ProPublica has a very helpful interactive map.

Legitimate budget concerns do exist. Many states are already struggling to pay for Medicaid as the economic downturn has raised the number of eligible beneficiaries (Medicaid is counter-cyclical; at precisely the time tax revenues decrease, the need for Medicaid dollars increase).

Of course, if a state chooses not to expand Medicaid, un- and under-insured moms, kids, seniors, and others will still need care. Those individuals will still need and receive medical care in emergency departments, at federally qualified health centers, and in temporary tent cities. And the cost of that care will continue to be born by public hospitals, shoved onto the uncompensated care side of the ledger, be partially made up by disproportionate share payments, and Medicare, after people become disabled from diseases like kidney failure. People will still miss work, have reduced productivity at work (presentee-ism), and spread disease because they can’t afford a sick day and/or medication. And the cost of all that? Estimated at a staggering $1 trillion dollars back in 2007.

What will happen now is unclear. Low-income individuals could get hardship waivers. The health benefit exchanges operated by the federal government (some states are refusing to implement and operate exchanges) could grant large or complete subsidies for low-income individuals to purchase commercial insurance. Political organizations could use the lack of health insurance as a major rallying point, and agitate for new gubernatorial and legislative leadership.

My preference would have been for the Supreme Court to rule that states either had to accept the Medicaid expansion or lose all their Medicaid funds. I very much doubt that any state would walk away from Medicaid altogether, especially a state like Florida, with so many seniors in nursing facilities which depend on Medicaid to pay ongoing costs.

States’ refusal to expand Medicaid will continue to have devastating consequences for the poorest, least able, most marginalized individuals and families. We will continue to spend the most, per capita, of any developed nation on health care and more as a share of GDP. We will continue to have, at best, middling outcomes in infant mortality, hospital admissions for diabetes, out of pocket costs exceeding $1000, life expectancy at birth, and premature mortality.

I am not so naive to believe that simply expanding Medicaid to 133% of poverty will instantly and for-all-time fix our health indicators. Medicaid is not a panacea for institutional racism, structural poverty, environmental degradation, and muddled education policy.

When Lyndon Johnson signed Medicaid and Medicare into law he said:

“There are those, alone in suffering who will now hear the sound of some approaching footsteps coming to help. There are those fearing the terrible darkness of despairing poverty–despite their long years of labor and expectation–who will now look up to see the light of hope and realization.”

With this ruling some governors will become lamplighters while others condemn their most vulnerable citizens to continued darkness.

Guest contributor Melissa Schober works on health care access and prevention policy, when she’s not busy mothering her young daughter. She started her political career in high school, lobbying for the passage of the Safe Schools Act. After 10 years in and around the D.C. Beltway with various women-focused health and policy groups, and a short stint in the private sector, she’s now one of those public sector employees the right routinely vilifies.

Melissa has served as an invited speaker for the Young Democrats Women’s Caucus, the Maryland Leadership Institute, hosted the inaugural chat at, and run more Advocacy 101 workshops than she cares to count. Her favorite food group is coffee.

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