Journalism in the Public Interest

The Affordable Care Act’s Most Important Date: Not What You Think

Forgotten amid the controversial health exchange rollout: The deep impact of last year’s Supreme Court ruling letting states opt out of expanding Medicaid.


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Many people have asked when we’ll know if the Affordable Care Act is a success or failure.

Was it Oct. 1, the date of the federal health insurance marketplace’s problem-filled launch? Or will it be the end of November, when is supposed to be fixed?

Is it Dec. 15, the last day consumers can enroll for coverage that begins on Jan. 1? Or March 31 when the enrollment period for buying insurance for 2014 closes?

In my mind, there is a different date that will have far more bearing on the number of people covered under the law. It’s June 28, 2012, the date the U.S. Supreme Court ruled on the act’s constitutionality.

What most people remember about the high court’s decision is that it upheld the core of the law: an individual mandate that requires practically everyone to buy health insurance or pay a penalty.

But the most consequential part of the ruling, which got less attention at the time, gave states discretion over whether to expand their Medicaid programs for the poor.

The law originally called for each state to expand Medicaid to people making less than 138 percent of the federal poverty level (now $15,856 for a household of one or $32,499 for a household of four). But the court said states could refuse to go along and not risk losing the federal government’s contribution to their Medicaid programs.

Why is this so important? Because about half the states have refused the expansion (or haven’t approved it yet), putting Medicaid out of reach for millions of their residents. Those states include Texas, Florida and almost all of the south. Here’s a map of what each state is doing.

We’re seeing Medicaid’s importance play out as consumers sign up for health coverage through the health insurance marketplaces. In fact, far more are enrolling in Medicaid than in private health plans. Consider this report Monday from The Wall Street Journal:

In Washington state, one of the states that operates its own exchange, 87% of the 35,528 people who had enrolled in new insurance plans from Oct. 1 to Oct. 21 were joining Medicaid plans, according to state figures. By Thursday, 21,342 Kentuckians had newly enrolled in Medicaid, or 82% of total enrollees. In New York, about 64% of the 37,030 people who have finished enrolling were in Medicaid.

Some states like Maryland, Washington and California are using aggressive outreach to get people into Medicaid, including contacting those who are already on other programs such as food stamps, said Matt Salo, executive director of the National Association of Medicaid Directors.

“When you actively go out and aggressively target people, they sign up,” he said.

It’s easy to understand why. Medicaid is free; private health plans may not be (depending on the subsidy a person qualifies for). Medicaid is relatively easy to sign up for; the private plans, not so much.

But in states that refused to expand Medicaid, millions of consumers are ineligible for this health coverage. The Kaiser Family Foundation has an interesting policy paper showing the consequences of these decisions.

Igor Volsky at Think Progress has a good roundup of this issue, as does Dan Diamond at the Advisory Board. Diamond has done a great job chronicling the states and their Medicaid expansion decisions.

For states, the decision to expand Medicaid seems like a good deal. The federal government has agreed to pick up 100 percent of the cost for the first three years, and its support will phase down to 90 percent. Governors who reject the aid say they don’t trust the federal government will keep its word; they believe health costs are unsustainable, and they don’t believe their states will have enough money to pay their share in the future.

So what’s going to happen? Health care organizations and consumer advocates are hoping that some states will reconsider and sign on for the expansion, as Ohio did last week, giving coverage to about 275,000 people. But some officials, including North Carolina’s governor, are holding firm against it.

Will that stance hold firm as millions of people in neighboring states receive coverage? If the start of Medicaid is any guide, the answer is likely no.

That said, it took 17 years for the last holdout, Arizona, to sign on. In 1982.

Read more about why broke down and four things to know about Kathleen Sebelius' Congressional testimony.

Make all future benefit changes only available vis the expanded coverage. So, that means if people live in a state that does NOT have the expanded coverage, they can not get the additional benefits. That will cause a major problem for conservatives everywhere because the voters will require the new Medicare be accepted or else they will vote for someone who WILL vote to accept it. Federal pie…. What conservative does NOT want it ALL?

It is so sad to see that we have become Republican States, or Democratic States and don’t remain the United States. What a farce and a tragedy for so many people who, with the help of Medicaid expension could live better, healthier and less stressful lives. Vote the hate mongers out.

I’ve quit making the mistake of voting for either the rrpublicans, or the democrats for the last time this past election.  I used to vote straight republican, until they became strictly the party of the elites of the far right.  I made the error of voting democrat for president this past election,  and won’t vote for the party of the party of the far left elites ever again.  NONE in DC represent WE THE PEOPLE. They represent THEM, THE RICH AND POWERFUL. The ACA was written by, and for the benefit of the powerful INSURANCE INDUSTRY, NOT for the benefit of the greater good,  and for the best interests of the health and well being of ALL AMERICANS. Those that represent The Military-Industrial complex,  that we were long ago warned against by a great General,  are against helping those who cannot afford to pay for healthcare. And, those who represent the Nanny State/Welfare State/Socialist State, want the middle class to carry the ENTIRE BURDEN by being the most heavily taxed. From now on I vote Pure Libertarian (not a RINO or ANY OTHER RIGHT WINGER IN DISGUISE), Constitutionalist,  or similar PURE ideology of return to a Constitutional Republic, which IS what The United States of America actually is. Even if my vote only does count as a small percentage,  it STILL COUNTS as a NO CONFIDENCE vote!

And now Virginia is added to the list.  26 States, D.C.

As to the three commentors before me:

jerry—no conservative wants any of the federal pie.  We want the federal government to stop taxing and controlling us and go back to what ist was supposed to do.  Military, foreign relations, and limited oversight of interstate commerce.

Karen—I wish unicorns with magical fairy dust were available to give us all stress-free lives, but that’s not life.  Some people have more than others.  They always will.  Our poorest are better off than the average in much of the world.  That’s saying a lot.  And I have no sympathy for a “poor” person who spends more on cell phones and television than I do.  Many poor are poor for a reason (my grandparents were poor, my parents very lower middle class, and I guess I’m upper middle class now (though certainly not near the level where money isn’t a constant worry).  That’s how it works.  Hard work and saving.  Not spending other people’s money.

Michael—don’t be a fool.  I like the Libertarians too.  But let’s get the Republicans in control and then we can have it out between the Libertarian wing and the special interests wing (I see agriculture subsidies as a much bigger problem than any military-industrial complex whatever the hell that is—at least the federal government is actually supposed to have a military while it has no place in the agriculture subsidizing business).

This: “What most people remember about the high court’s decision is that it upheld the core of the law: an individual mandate that requires practically everyone to buy health insurance or pay a penalty.”

If that is what “most” remember, their memory is faulty.

SCOTUS reinterpreted that “penalty” as a tax and that is the only reason the bill was ruled constitutional. The “penalty” term did not pass muster.

The bill is a tax bill. I hope you read the bill. I did and in the long run, most will realize what an utter failure this faux reform is.

David Z.

The purpose of the US Constitution is to define the responsibilities of the govt to the people. Promoting the general welfare is specifically stated within the Preamble. Providing for the common defense is also stated. If you want one, you want the other. The failure of the healthcare system needs to be addressed at the federal level because that is the only level with the capability of handing it. States can not.

Kay B:

The USSC determining the penalty is a tax is no big deal. Fees are taxes also—just not CALLED a tax.

David Z.
Speaking of fools. I saw just now where Mitt Romney (that absolutely foolish, clueless, secretive, super wealthy one percenter) is forecasting that Paul Ryan (very scary politics), and Chris Christie (RINO) as the GOP top choices for 2016! That’s a sure way for that extremely dangerous woman Hillary Clinton (who is cleverly hiding her full intentions to run until the last possible minute so she can dodge controversy) to get elected. We need Herman Cain, or Rand Paul. They’re the ONLY republicans that I would cast my vote for, unless you can revive Ronald Reagan! I agree that the agricultural subsidies, most especially the CORN subsidies (that’s why there’s corn syrup instead of real CANE sugar in everything, and that damnable ethanol that’s ruining our engines plus lowering mileage) need to be done away with. Please do a Google search on The Military-Industrial Complex, you’ll see why we keep getting involved in foolish, unfounded, and constitutionally illegal wars, plus the grotesque amounts of money that are wasted on foolish, unneeded, quickly outdated/outmoded hardware, and why this General explicitly warned us against it. You’ll be quite surprised WHO that General actually was. It IS a HUGE problem, nonetheless. Our NATION does need a strong NATIONAL defense, but we need to stop this foolishness of acting as the worldwide police. Let THEM spend their OWN damned money on THEIR national defense, and quit relying on the good ole USA to provide it for them. It’s time to be a little more isolationist. Worry about our own. Feed, and clothe, and house, and heal, and educate, and protect OUR OWN FIRST. THEN, maybe, worry about the rest of them.
‘Nuff said.


Corn syrup (HFCS) is *more profitable* to use than real sugar—so the various companies use it for that reason. Sugar beet farmers would go NUTS if there was demand for real sugar again—or if US protection of the sugar beet growers was dropped and the import of sugar from (almost) anywhere—i.e. “free market” sugar—was allowed with no tariffs. There is currently a massive oversupply of sugar worldwide. Oh yeah, the US does NOT grow much cane sugar because it is more profitable to grow almost anything else on that land.

Reagan was a HUGE supporter of govt. 16-million additional jobs were added while he was President. Sound like a lot? It is NOT. 2-million jobs were added EVERY YEAR—on average—from 1971-2001. 1971 = 71.3-million workers. 2001 = 131.3-million. Do the math. Now comes the REAL crusher. 25% of the jobs created UNDER REAGAN were IN GOVT (at all levels—fed + state + local). Fact—from BLS. So. Reagan did the OPPOSITE of what conservatives are doing today. Or, should we say, conservatives TODAY are doing the OPPOSITE of what Reagan did. Yet Obama keeps adding jobs—ALL in the private sector, with NEGATIVE govt employment.

This article is part of an ongoing investigation:
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