What will be the consequences of the now-OPTIONAL Medicaid ACA expansion?

This seems to be the big caveat in the ACA SCOTUS ruling that few people have seemed to be discussing. Yes, the ACA has passed constitutional muster for the most part, as the intended Medicaid expansion mandated in the law - a provision that will ostensibly generate more insured people than the infinitely more contentious individual mandate - has now been deemed to be unconstitutionally coercive. Though the measure was not invalidated, the states now have the option to either (a) expand their Medicaid program as per the ACA and subsequently adhere to all of the federal stipulations that that action will imply, or (b) leave their Medicaid programs as they were before the ACA was passed. That’s my understanding of the ruling anyway.

What will be the practical effects of this SCOTUS caveat in terms of the successful implementation of the ACA? I said in an earlier thread that I think it’s unlikely that ANY state (save for super Reds like Mississippi or something) will ultimately say “no” to all of the federal funding that would go along with their expansions of their respective Medicaid programs, but that possibility still leaves the door open for a stark alternative. Basically, there might be MASSIVE gaps in coverage between the liberal states that accept the expansion (California, Vermont, Massachusetts, etc.) against the conservative states that hold out.

What do you guys think will be the practical outcome in this case?

Your analysis is spot on about what the court ruled.

The blue states will all sign on to the expansion, no problem. At least some of the red states will not. I’ll guess about a dozen won’t.

Medicaid currently covers the blind, disabled, pregnant women, and needy families with children with an income at or below about 33% of the poverty line. The expansion will cover anyone with income (individual or family) up to 133% of the poverty line. Still woefully poor.

In those states that opt out you will still have many people caught in the gap. A single able bodied adult with income of 50% of poverty line is still terribly poor. He will most certainly choose food and shelter over insurance. He won’t even look to the exchanges. He does not have enough money to pay even a subsidized premium. He’ll end up in the ER for most medical needs, just as before PPACA.

I think this will shake out similar to the stimulus money that flooded the states in '08. In the end, even the states most vociferous in opposition accepted the money. Granted, the Medicaid expansion will eventually mean more contributions from each state, but it won’t at the outset. I can’t imagine too many governors turning away federal dollars, especially as their constituents watch those in other states benefit. Keep in mind Republicans are under increasing pressure to appeal to minority groups, particuarly the rapidly expanding Hispanic base. Those same minority groups will represent a large percentage of those eligible for expanded aid, and the last thing any governor can afford (at least for long) is to ignore those voters. Plus, the states who turn away the expansion will still be paying federal taxes that will be used to pay for benefits to the states who agree to the expansion. I just can’t see even the reddest states turning it away for long.

The people who will be most affected by Medicaid expansion opt-outs are those who are least likely to vote Republican or most likely to vote Republican no matter what. Cynical Republican governors, therefore, will opt out. Others won’t.

Then there’s Rick Scott, who is busily disenfranchising all our Medicaid recipients anyway.

This article claims that HHS can setup a federal exchange for states that don’t setup their own.

The problem is that it doesn’t provide any funding for it, probably because, before the SCOTUS ruling, they didn’t think any states would opt out. The article does, however, give some possibilities for funding such an exchange even if direct funds aren’t available.

For example:

Yea, keep in mind it doesn’t make any difference who opts in or out till 2014. Assuming the ACA survives the next election, I suspect that between 2012 and 2014, a lot of red-state governors who said they’d opt out will quietly accept the money. A few hold outs will (like Rick Scott) will eventually leave office and their successors will accept the money and at most, all but one or two small red states will have joined the program by 2016.

It does make a difference, though. You can’t set up these things overnight; a two year delay now means at least a two year delay in actually implementing the thing. Plus, businesses have been scrambling to prepare for exchange-based markets*, and now they’ll have to scramble to remain prepared for conventional ones in some states.

*the general expectation in the insurance industry is that in most states employers will dump all their employees on the exchanges and let them spend their own insurance contributions.

I was just talking about the Medicaid expansion,which I think was all the OP was talking about as well.

The exchanges will take some time to set up, but as davidm notes, states can’t op out of those. The feds can do it themselves if the States won’t (though apparently it will take some creative financing if the House won’t appropriate funds).

(plus as far as ideology goes, it seems a little silly for Conservatives to opt for giving up state control of the insurance exchanges).

Some relevant politician in Mississippi made this exact point in an NPR report this morning. “Better that the exchange be run for Mississippians by Mississippians than by the feds” was his basic argument.

His approach to the Medicaid funding was quite a bit less intense than I would have expected - more of a “wait and see” than “hell no”.

For states like Mississippi, without much of a tax base and with a large population of people below the poverty line (20% in Mississippi), forgoing a Medicaid expansion that’s 90% funded with other peoples money would be pretty painful, even if its “Obamacare money”. And its largely red-states that are in that position, which is another reason I don’t expect resistance to the expansion to really last beyond 2014.

Oops, I think we’re conflating insurance exchanges with Medicaid expansion. This thread was about Medicaid expansion. The article I linked to is about insurance exchanges. Two different things. My bad. :o

This largely affects childless adults with incomes less than 133% of the Federal Poverty Level. The consequences will likely be that conservative states will not implement the Medicaid expansion on principle. It will mean that the ACA will only expand coverage to about 2/3 of the original number of people it was expected to expand coverage to. Whenever a Democrat is elected into office in those states he/she may implement the expansion (will this become an issue to campaign on for state political races?).

Longer term however, this is really the first time that the feds power to expand social welfare programs has been challenged, so there could be very serious challenges to any future efforts to expand federally-funded programs (medical or otherwise). States must now be presented with the opportunity to say no to expansions to programs they initially signed on to, which has not been the practice to date.

If it doesn’t become a campaign issue then there is some major political malpractice going on. Giving up free money to cover poor people (and that you are paying taxes for anyway) is the definition of bad politics.

I think you’ll just see Congress being a bit more explicit about what they’re doing.

I don’t see how a bill that completely eliminates Medicaid and then creates a new, bigger opt-in Medicaid can be invalidated by SCOTUS, for example.

The federal government could definitely do that- although it would be incredibly complex to essentially dissolve the current program. I would imagine it would have to be a true elimination of the current program and then of course the replacement program (Medicaid 2.0) would be hailed as universal health care, and opposed on those grounds. I think the real risk you’d run (from the current administration’s perspective) is that some states would simply completely opt-out.

Wyoming did a really interesting analysis in 2010 of what would happen if they decide to opt-out completely of Medicaid (PDF of their analysis). Interestingly, you’d end up with a situation where emergency medical care is still mandated by EMTALA, but no preventative care program exists for poor populations. So you’d have a huge crunch on EDs, which I think the general public would find unacceptable, even if they oppose Medicaid for idealogical reason.

Except that newly-elected GOP governors of three states – Wisconsin, Ohio, and Florida – followed all the way through on their campaign rhetoric to reject a specific portion of the stimulus, high-speed and intercity passenger rail. This despite – or more likely because :rolleyes: – their predecessors in office had actively applied to the Feds for the money. The HSIPR funds – over $2 billion from FL, $800 million from WI, and nearly $400 million from OH – were reassigned to the next states down the application list.

These governors ran for office on “ideological” opposition to passenger rail as a policy or program, in contrast to the stimulus as a whole, and at least one of them (Scott Walker of Wisconsin) unsuccessfully asked if the Feds would grant them the same sum of money for highway projects. :dubious:

I can see at least some of the more fire-eating GOP governors sticking to their guns on their “ideological” opposition to “Obamacare”. They aren’t rejecting all Federal aid, only the money tyrannically calculated to force down their throats* their endorsement of unconstitutional and socialistic Obamacare. :rolleyes:

*Forcing down throats always seems to be involved in these things. Oral fixation, a Freudian would say. :slight_smile:

This is essentially the mechanism by which Canada got UHC. The Canadian Constitution puts health care 100% in provincial hands, so there was a problem when the feds wanted to bring in national UHC. The solution - make UHC completely optional for the provinces, but heavily subsidize the ones that implemented it. Voter pressure led to all remaining provinces being included within 6 years (several had already implemented some form prior to the initial 1966 federal act).

I’m sure you’re right… at least for awhile. I remember Rick Perry in Texas flapping his gums along those same lines… even though he caved. How long those tough-talking governors will hold out depends on how many of their constituents will miss out on assistance because of that stance. It’s one thing to turn away what amounted to a lump sum payment. It’s another entirely to forego a federal program that will cost your states millions of dollars every year.

Fair enough – there’s time for an intransigent governor to eventually “repent” on the Medicare issue. For HSIPR, there was an application process with total applying projects bigger than the total grant available, so there were several rejected applicant governors clamoring in the wings after the rejections.