What Will the Supreme Court do to Medicaid?

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By now, just about everyone knows that the Supreme Court is reviewing the Patient Protection and Affordable Care Act. The Court is spending three days – an eternity by normal argument-length standards – considering the finer points of what exactly constitutes a tax, how a tax differs from a penalty, and the finer points of the interstate commerce clause.

The last of the arguments, to come on Wednesday afternoon, will be Florida v. Health and Human Services. The question before the Court is whether the federal government can require states to expand their Medicaid eligibility and whether, if states refuse, the feds can withhold all of a state’s Medicaid funds. Florida is decrying this as coercion and asking the Court to rule against the Medicaid expansion.

The Affordable Care Act is a remarkable piece of legislation with many remarkable provisions. For the first time money is specifically set aside for research on prevention and wellness (Title IV); there are provisions focusing on health information technology to prevent medical errors; there are all-carrot-and-no-stick provisions encouraging Medicare beneficiaries to get annual screenings. Also included in the thousands of pages is a provision that would expand Medicaid coverage to all individuals with incomes at or below 138% of the federal poverty line, a little more than $30,000 for a family of four in 2011.

Many labor under the misconception that Medicaid provides free and generous health benefits to any low-income person. In reality, states are only required to cover impoverished children (including those in foster care), pregnant women, some disabled persons, and some adults with dependent children. More than 2/3 of Medicaid spending pays for services for the disabled and for care of the elderly in nursing homes; children consume about 20% of the total funds.

Childless adults, even those with incomes far below the poverty line are not automatically eligible for Medicaid. Nor are the parents of Medicaid-eligible children automatically eligible for coverage. For example, in Alabama, parents’ incomes cannot exceed 24% of the federal poverty line – less than $5000 a year for a family of three. Eleven other states all have income eligibility well below the FPL. Even richer more progressive states limit coverage: Maryland covers childless adults with incomes up to 116% of the federal poverty line but the benefit package does not include inpatient care.

The Medicaid expansion, which would begin in 2014, would be entirely paid for by the federal government for the first few years, with the feds continuing to pay the lion’s share for years to come.

States, led by Republican Governor Rick Scott are arguing that this expansion is far too onerous. In light of this argument, I am startled that Governor Scott continues to accept federal highway funds; after all; states are required – or is it coerced? – to set and enforce a drinking age of 21 or lose 10% of funding. Florida accepts federal education funding in exchange for administering a plethora of tests as required by the dubious wisdom of the No Child Left Behind Act. If Governor Scott finds the Medicaid expansion so very troubling, why isn’t he rushing to challenge every federal dollar that comes with any sort of string attached?

Setting aside Governor Scott’s inconsistent response to federal largesse, I wonder if he has toured an emergency department lately. Where does he think low-income Floridians go for care? Some might be able to scrape together enough for the occasional preventative visit, or live near a federally qualified health center with a sliding fee scale, but many uninsured seek care in a hospital setting where they cannot be refused care. At this very moment uninsured Floridians are sitting in emergency departments driving up the uncompensated care side of the ledger.

Uninsured Floridians don’t live in isolation either. They mow lawns and for lack of routine booster immunizations spread pertussis. They wipe their feverish brows in break rooms before delivering your eggs over easy. They are swallow two ibuprofen in an attempt to thwart shingles pain before turning someone’s senile grandmother to prevent bed sores.

When Governor Scott thinks of the Medicaid expansion, I’d wager that he sees the federal ball and chain. I see a laborer, a day care worker, a grocery cashier. I see lives cut short, years of productivity and happiness lost to preventable, treatable conditions.

I invite readers to take an active part in helping others to conjure up similar images. And I invite you to read President Johnson’s words when he signed another social safety net program – the very one-off which Governor Scott’s own wallet grew fat – into law:

Many men can make many proposals. Many men can draft many laws. But few have the piercing and humane eye which can see beyond the words to the people that they touch. Few can see past the speeches and the political battles to the doctor over there that is tending the infirm, and to the hospital that is receiving those in anguish, or feel in their heart painful wrath at the injustice which denies the miracle of healing to the old and to the poor. And fewer still have the courage to stake reputation, and position, and the effort of a lifetime upon such a cause when there are so few that share it.

But it is just such men who illuminate the life and the history of a nation.

When you go to your voting place in November, I hope you will carry these words with you. I hope you will think on them before voting. I will be casting my vote in favor of more light for an America that has grown all too dim.

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 TheMotherhood.com, and run more Advocacy 101 workshops than she cares to count. Her favorite food group is coffee.

  • Helen

    We are told we live in the world’s wealthiest nation. We should be the most embarrassed nation in the world when we refuse to offer the basic human necessity of caring for the sick and finding ways to pay for prevention to keep illness at bay.

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