The Affordable Care Act envisions a major expansion of health insurance in America, with some 30 million Americans gaining coverage. That figure includes some 17 million people with low incomes who were to get health insurance via an expansion of Medicaid eligibility. With eligibility raised—from 100 percent of the poverty level to 133 percent—many states will enlarge their Medicaid rolls and pay for it with federal funds, at least for a few years.
But the Supreme Court clouded that part of the vision last week, ruling that states cannot be penalized for refusing the federal money—thus leaving in doubt how many of the projected 17 million poor or near poor citizens will actually get coverage.
In short, the Supreme Court allowed the federal carrot to remain, but took away the stick. Matt Salo, the executive director for the National Association of Medicaid Directors, an organization for those who run state programs, summed it up for The Washington Post: “Prior to the court’s decision, failure to implement this expansion meant you [the states] lost all your Medicaid funding. Now you have a political and financial decision to make: Do you do this?”
So that was one of the big issues the press tried to address last week in its coverage of the court’s ruling. During the run-up to reform and in the 2 years since the law passed, the press has treated Medicaid as the health system’s stepchild—mostly ignoring what it does and its importance to the 60 million Americans who already count on it for medical care. Medicaid stories rarely win popularity contests with editors. But given the drama surrounding the overall decision, and perhaps because the Medicaid expansion is the one place that the health reform bill came up short in the ruling, the press is paying attention now.
And the media narrative is that a big part of the health reform battleground has shifted to the states. “The ruling creates a new arena for political battles in the 26 states—primarily Republican—that sued to overturn the law,” reported Kaiser Health News. Many stories made this point and supported it with comments from Republican governors who so far don’t appear keen to expand their programs. “We’re not going to shove more South Carolinians into a broken system that further ties our hands,” Rob Godfrey, a spokesman for Gov. Nikki Haley, told The Wall Street Journal. From the Christian Science Monitor we learn that Mitch Daniels, the governor of Indiana, said that the Medicaid expansion would put one in four Hoosiers, or about 500,000 new people, into the program at a cost of $2 billion over ten years. The reform law calls for the federal government to pick up all the costs of the Medicaid expansion from 2014 to 2016; after that, the states would begin gradually paying a portion of the cost, though the fed share though would not fall below 90 percent. Nonetheless Daniels, like several other GOP governors, argues that the provision is a budget buster. Daniels said his state would instead try to put more people into an existing local program, the Healthy Indiana Plan. Time noted that Texas Gov. Rick Perry “has indicated he intends to resist implementation of the ACA.”
The Los Angeles Times hinted at the equity issue raised by the Medicaid ruling when it reported that the court “opened the door to something the president and other champions of the law sought to avoid—widening disparities between red and blue states in who gets health care. Under the court’s ruling, states will be free to elect not to cover all of their poor residents through their Medicaid programs.” Indeed that may be the case. West Virginia Sen. John D. Rockefeller IV put it this way:
When we wrote the law, we worked very hard to make sure that low-income Americans who aren’t currently eligible for Medicaid but still can’t afford to pay for health insurance are given an affordable option through the expansion of Medicaid. [The Supreme Court] could have seriously undermined their healthcare options.
How the decision will affect poor people who need healthcare is the next Medicaid story the media should consider. The New York Times’s good second day piece laid out the problem: “Under the law, subsidies are available to people with incomes from the poverty level up to four times that amount, but not to people with incomes below the poverty level ($23,050 for a family of four).” What happens to them?
Speculation about what this governor or that governor will do—or what the consultants and pressure groups, such as hospitals that need patients who can pay, will tell them to do—is fine. But it is not the essential Medicaid story that needs to be told.
That story is about people: What will really happen to low-income people who would have been captured in the expansion of the safety net had the court ruled another way, or now if they lived in a bluer state. How will they pay for their health care? How do they do so currently, if they do? Will they be eligible for subsidies the law makes available for the uninsured? If so, will such subsidies be large enough to buy decent insurance?
What will substitute programs like the one Mitch Daniels talks about for Indiana actually provide? This is the nitty gritty of local reporting, and political speculation does not substitute for it.
Then there’s the larger question that Darshak Sanghavi, writing for Slate.com, zoomed in on: “State reluctance to expand Medicaid gets at the core problem in health care today—it’s just too damn expensive and the ACA does very little about that.”
Serious exploration of the law’s weak cost control measures might be in order too.