For supporters of the Affordable Care Act, it was hard to hear—over the cheering—anything besides the fact that the Supreme Court today kept the law almost entirely intact. But the Court did make a slight change to a crucial part of the ACA: Medicaid expansion. Under the law, by 2014, states are supposed to extend their Medicaid programs to cover people under 65 with incomes up to 133 percent of the federal poverty line. An analysis from the Center on Budget and Policy Priorities shows that means 17 million more people would have access to health care over the next 10 years. Before today, it looked like states didn't have much choice in the matter. If they didn't make the necessary expansion, they would lose all federal Medicaid dollars. In their brief, states argued that wasn't much of a choice—federal Medicaid grants simply constitute too much money to lose. Back in February, Timothy Jost had a very helpful explanation of the states' argument on this point in Health Affairs. As he wrote:
A state that refuses to expand its Medicaid program will under the ACA lose all Medicaid funding. Medicaid is the single largest source of federal funding to the states, accounting for 40 percent of all federal money dispersed to the states. States do not really have a choice to walk away from federal Medicaid funding, they argue. The states do not, therefore, really have a choice to refuse to participate in the Medicaid expansions. This coercion, the states contend, is unconstitutional.
According to SCOTUS Blog, the Supreme Court basically agreed: The feds can't cut all Medicaid funding for states that refuse to expand. Now, states that choose not to extend benefits will forgo the money they would have received for doing so—but they won't lose the money they're already getting for current Medicaid services. But while states can now avoid the extension more easily, there's still no practical reason to go down that path. "It's still an incredibly good deal for the states," says Edwin Park, vice president for health policy at the Center on Budget and Policy Priorities. Already the federal government pays, on average, 57 percent of Medicaid costs. But the ACA gives states much higher levels of funding when it comes to extending benefits. As a CBPP report in March noted, the feds will pay a whopping 93 percent of the costs of expansion over the next nine years:
Specifically, the federal government will assume 100 percent of the Medicaid costs of covering newly eligible individuals for the first three years that the expansion is in effect (2014-2016). Federal support will then phase down slightly over the following several years, and by 2020 (and for all subsequent years), the federal government will pay 90 percent of the costs of covering these individuals. According to CBO, between 2014 and 2022, the federal government will pay $931 billion of the cost of the Medicaid expansion, while states will pay roughly $73 billion, or 7 percent.
That means, all in all, states will only see a 2.8 percent increase in what they would have spent on Medicaid if there was no health-care bill. The expansion is also in the interests of health-care providers. The ACA was meant to vastly decrease the amount of health care hospitals have to provide with little or no compensation. It was for that reason, Park says, that providers agreed to reductions in Medicaid and Medicare rates. But without the Medicaid expansion, working adults who are too poor to afford health care but not poor enough to qualify for Medicaid could still be left without coverage in some states. "Now there's going to be a donut hole in the middle if the state doesn't proceed," says Park. That's bad business for hospitals. There's another factor that states will have to consider: the savings they will realize as populations begin to get healthier. According to the CBPP report, there will be 33 million fewer uninsured people by 2022. Uninsured people are expensive; they often rely on expensive emergency-room care, rather than getting preventative and early treatment which is ultimately cheaper and more effective. The Urban Institute reports that in 2008, $10.6 billion in state and local dollars went toward hospital care for the uninsured—20 percent of the total costs. The percentage is even higher when it comes to mental-health services. With the expansion, those costs will likely go down dramatically. States may have the option now to forgo the Medicaid expansion. But the results won't be pretty.