Full implementation of Affordable Care Act medicaid expansion at risk

by Brian Wolfman

After the Supreme Court last summer held (7 to 2) that the Affordable Care Act's medicaid expansion could not be forced on the states under the Constitution's so-called Spending Clause, it was left to the states to decide whether they wanted the expansion. Medicaid expansion under the ACA is broad, providing coverage to people
with incomes up to 133% of the federal poverty level. Medicaid expansion
is thus a central component of the ACA's promise to make health care
coverage available to all (or nearly all) Americans. But, in light of
the Supreme Court's ruling, without cooperation at the state level, many
Americans will remain uncovered.

Under the Supreme Court's decision, the expansion seemed like an offer that the states could not refuse. Under the ACA, the federal government pays 100% of the new recipients' medicaid costs for the first three years of the program and at least 90% after that. But political opposition to the ACA runs very deep. We have posted repeatedly on the politics surrounding the states' decisions whether to accept the funding or not. Go, for instance, here, here, here, and here.

This article by Sandhya Somashekhar in today's Washington Post explains that in some states where Republican governors are ready to accept medicaid expansion, Republican-controlled legislatures have not been willing to go along. The expansion is slated to begin in January. But according to Somashekar's article, only 23 states and D.C. have accepted the expansion, a whopping 19 have rejected it, and 8 are still debating it. States that reject expansion can accept it down the road. But meanwhile, full implementation of the ACA for the people most in need is in serious jeopardy.

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