Chief Justice John Roberts, backed by Justices Elena Kagan and Stephen Breyer, reached one appalling conclusion in NFIB v. Sebelius: that the federal government's ability to provide for the general welfare is sharply limited. It may not require states to provide Medicaid health insurance to those at up to 133% of the federal poverty line. Governors like Paul LePage of Maine who practice the "why should I pay for your health care" politics of resentment have made grandstanding statements that they will not expand medicaid, or even drop out entirely, as did Rick Perry of Texas.
Medicaid expansions were associated with a significant reduction in adjusted all-cause mortality (a relative reduction of 6.1%). Mortality reductions were greatest among older adults, nonwhites, and residents of poorer counties. Expansions increased Medicaid coverage, decreased rates of uninsurance, decreased rates of delayed care because of costs , and increased rates of self-reported health status of “excellent” or “very good”Profs. Timothy Jost and Sara Rosenbaum explain in an accompanying op-ed in the New England Journal of Medicine that
the Medicaid expansions are accompanied by 100% federal funding for the first 3 years, phasing down to 90% by 2020. The ACA offers no other means for covering adults with incomes below 100% of the poverty level. Resisting states effectively intensify the huge uncompensated care burden faced by their hospitals, deprive other health care industry players of important revenues, and keep their medically underserved communities from receiving an enormous economic infusion. Indeed, there is good evidence that overall, the changes in Medicaid will save, rather than cost, money.5 And residents of states that do not expand will still be paying federal taxes to cover the expansion in states that do expand.
Given the clear language of the Court's decision, the July 10 letter [from the Department of Health and Human Services] permits states to decide whether to accept funding to support the Medicaid expansion for newly eligible adults as a group or to reject it and with it hundreds of billions of dollars in much-needed federal assistance.
But some states may press the administration to interpret the expansion as a simple state option, allowing them to cover some portion of the expansion group and not others. This approach has no support in the law and would invite states to leave the most vulnerable members of the expansion group — adults without children — exposed to the worst sort of discriminatory exclusion. The administration may be pressured to enter into negotiations with each state, using its waiver authority. The ACA specifically amended the Medicaid waiver process to ensure that it was used for genuine research, not political horse trading. One can only hope that the states will come to their senses and we all will be spared the spectacle of federal and state governments struggling over the lives and health of the poorest among us.