The Supreme Court and the Future of Medicaid (New Eng Jour Med)

[pinto]

The Supreme Court and the Future of Medicaid

Timothy Stoltzfus Jost, J.D., and Sara Rosenbaum, J.D.
July 25, 2012

Perhaps the biggest of the many surprises found in the Supreme Court's June 28 decision on the Affordable Care Act (ACA) was the Court's conclusion that the law's Medicaid expansion scheduled for 2014 was unconstitutional.1 Attention before June 28 was focused on whether the Court would uphold the individual mandate to obtain health insurance coverage, but in the wake of the Court's decision, focus has shifted to the question of whether states will refuse to participate in expanding the Medicaid program, given the Court's holding that the Secretary of Health and Human Services cannot enforce the expansion as a mandate.

Sommers et al. now provide in the Journal a glimpse of the impact of Medicaid expansion in New York, Maine, and Arizona. Medicaid expansion in these states was associated not only with improved health care coverage but also with reduced mortality. The question of whether the states will expand Medicaid, therefore, is not just a question of politics; it is a question of life, health, and death.

The expansion is one of several important Medicaid changes in the ACA. But as Justice Ruth Bader Ginsburg noted in her opinion, changes in Medicaid are not new. Medicaid itself was established in 1965 as an amendment to the preexisting Medical Assistance for the Aged program. Since then, Congress has amended Medicaid at least 50 times, mandating coverage of new categories of beneficiaries (e.g., low-income pregnant women in 1988) and dramatically expanding coverage for others (e.g., low-income children in 1989). Indeed, the Social Security Act has always reserved to Congress “the right to alter, amend, or repeal any provision” of the Medicaid statute.2 The ACA's expansion of Medicaid to cover all nonelderly low-income persons with household incomes below 138% of the federal poverty level was the latest in a long line of evolutionary program reforms.

The 26 state challengers claimed that the ACA Medicaid amendments crossed a constitutional line. It is clear that Congress cannot force states to participate in a federal program. The Court has long recognized, however, that the federal government can offer funding to the states conditional on their satisfying program requirements. The Court had speculated in earlier cases that a situation could arise in which “the financial inducement offered by Congress” was so coercive that “pressure turns into compulsion.” But no federal court had ever held that a federal law failed this test, and the lower courts rejected the states' Medicaid claims.

http://www.nejm.org/doi/full/10.1056/NEJMp1208219?query=TOC