by Brian Wolfman
After the Supreme Court's decision last June largely upholding the Affordable Care Act (ACA), we asked this question: Which states, if any,
will back out of the Medicaid expansion?
As you will recall, the Supreme Court ruled 7-to-2 that the states have the right to back out of the ACA's large Medicaid expansion — that is, the states don't have to
participate in the expansion if they turn down the federal funds
available as part of that expansion (but they can still participate in
the pre-existing Medicaid program). Also recall just how large that expansion is. The ACA seeks to cover most of the millions of
Americans who lack health insurance using several methods, and none is bigger
that the Medicaid expansion. With the expansion, nearly all Americans
with incomes up to 133% of the federal poverty level are eligible
for government funded medical care (if they live in states that don't opt out, that is). Before the ACA, Medicaid eligility
not only required poverty — extreme poverty in some cases — but also
inclusion in a category, such as disability, being above or below a certain age, etc.
Moreover, under the Medicaid expansion, the federal government funds all of the new Medicaid costs for the
first two years of the expansion and at least 90% of it after that. So, in the long run, it's always struck me as unlikely that many (if any) states would opt out. But Florida's Governor, Rick Scott, was one of the Republican governors who hated the ACA and said, after the Supreme Court's decision, that his state would opt out of the Medicaid expansion.
As explained in this article by Sarah Kliff, Scott has changed his mind and now will accept the Medicaid expansion for his state (for at least three years, he says). Why? He says that “I believe in a different approach. … But it doesn’t matter what I believe. The Supreme
Court made its decision. We had an election in the fall, and the public
made their decision. Now the president’s health-care law is the law.” But "the Supreme Court and the election made me do it" argument is just an attempt at gaining political cover. The Supreme Court's decision expressly authorizes Florida to opt out. He's participating now because it makes sense for his citizens to participate. Low-income people in his state, many of whom have no insurance, will receive health care, and the feds will foot almost all of the bill. That's a great deal for Floridians, isn't it? (Kliff's article says that "In Florida, analysts expect the Medicaid expansion to cover 1.3 million
people and bring $73 billion in federal funds into the state over the
course of a decade.")
Some states still say that they are going to opt out. Virginia's governor, for instance, says that he won't accept the Medicaid expansion unless the program undergoes "major reforms." But I suspect that eventually (if not immediately) all states will follow Florida's path.
UPDATE: This article by Phil Galewitz explains why "[a]lmost overnight, Florida has gone from being an ardent opponent of the
federal health-care law to a laboratory for an ambitious experiment