Supremely kicking the uninsured -- July 19, 2012 column

By MARSHA MERCER

When the U.S. Supreme Court upheld almost all the Affordable Care Act last month, analysts gushed that it was a stunning victory for President Barack Obama.

It’s becoming clear, though, that the court’s ruling on the Medicaid provision may be a bitter disappointment for low-income workers who are uninsured, especially in the South.

A central promise of the Affordable Care Act is that it will relieve the anxiety and financial insecurity of having to live without health insurance. Most of the uninsured have jobs or live in a household with someone who does, but their employers don’t offer health insurance, they aren’t eligible because they work part-time or they can’t afford the premiums.

Obamacare, as the law is known, provides carrots and sticks for people to obtain affordable health insurance. That’s where Medicaid, the nation’s largest health program in terms of participants, comes in. About 60 million Americans receive health care through Medicaid. About three-fourths are poor children and families and one fourth are elderly or disabled. Seven in 10 nursing home patients are on Medicaid.

The idea was to bring coverage to about 16 million more Americans by 2019 by adding a new category of Medicaid eligibility: adults without children who are under 65, not disabled, and whose income is near the poverty line.

The law presented states with an offer they couldn’t refuse: Expand Medicaid in 2014 to people whose incomes are within 138 percent of the federal poverty level -- $26,344 for a family of three in 2012 -- or forgo all existing federal Medicaid funding.

But Chief Justice John G. Roberts Jr., writing for the majority, said such “economic dragooning” left states no real choice but to participate in the expansion. The court struck down the funding restriction, and states now have the option of rejecting the expansion and sticking with their current Medicaid program without penalty.

Sadly, that means health coverage now depends on geography, with many low-income Americans who can’t afford insurance in limbo and at the whim of their governors.

So far, only a handful of governors will definitely implement the expansion. About a dozen governors, many in the South, have said they may or will reject expansion.Republicans Rick Perry of Texas and Rick Scott of Florida will reject. Those leaning against expansion include Alabama Gov. Robert Bentley and Virginia Gov. Robert F. McDonnell, both Republicans. Tennessee Gov. Bill Haslam, a Republican, is mulling whether to ask for a block grant to run his state’s program. A lump sum payment would come with fewer strings as to how the program operates.

The governors say their main worry is cost, and yet the federal government will pay for expanding Medicaid at first. Uncle Sam will pay 100 percent of the costs for new enrollees for the first three years. After that, states would begin sharing in the new costs, up to 10 percent.

Turn down free money? Highly unlikely, the Obama administration thought. Some veteran political watchers still predict balky states won’t turn down the money come the 2014 election cycle.

The court has left the decision up to each state at a time when the fiscal and political forecast is stormy. A new report on states’ fiscal health by respected economists predicted financial woes that will last long after the economy finally rebounds.

Complicating the matter is a provision in the health law that says those who don’t qualify for Medicaid will be able to get insurance through new marketplaces called exchanges. Those who can’t afford the premiums will be eligible for subsidies.

States are expected to set up the exchanges, but many states have been slow to get started. As with the Medicaid expansion, some may pass. If a state won’t set up an exchange for its residents, the federal government will step in. But there’s yet another catch.

The law says that the uninsured can get subsidies for premiums on state-run exchanges. It doesn’t say subsidies will be available for premiums on federally run exchanges.

That glitch too can be worked out – if there’s a will.

For now, millions of working Americans who lack insurance are still pawns on the great political chess board. And that’s a shame. We can and should do better.

© 2012 Marsha Mercer. All rights reserved.

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