Supreme Court ACA Ruling at 1 Year: Many States Fleeing Medicaid Expansion

Leigh Page

June 27, 2013

In This Article

It's been a year since the US Supreme Court delivered its surprising 2-part decision on the Affordable Care Act, and physicians are just beginning to feel the effects.

While the justices upheld the individual mandate to buy health insurance, they weakened the ACA's plans to expand Medicaid by some 16 million people. The June 28, 2012, decision ruled that the federal government could not force states to accept the Medicaid expansion.

Now, a year later, almost half the states have indicated they will opt out of the expansion, canceling coverage for millions of low-income people who had been expected to join Medicaid rolls on January 1, 2014.

Molly Cooke, MD, president of the American College of Physicians and professor of medicine at the University of California–San Francisco, says the court's decision will have a profound effect on the nation's social safety net. "The big story of 2013 and 2014 is what states are going to do with their Medicaid programs," she said.

What happened in the past year is "sort of amazing," Dr. Cooke added. When the Supreme Court released its decision, it was far from clear that states would take advantage of it and opt out, because that meant rejecting a great deal of "free" money. Federal funding for Medicaid is usually tied to states paying hefty matching funds, but under the ACA's expansion, the federal government will cover 100% of the costs for the first 3 years and 90% after that.

Now, a surprising number of states are walking away from this tempting offer. At last count, only about half of the states will accept the funding and 18 states have rejected it outright. The rest are still deciding, but most are leaning toward opting out.

The decision creates a new divide between states such as California, New York, and Illinois, which will accept the funds and significantly grow their Medicaid populations, and those that will not, such as Texas, Pennsylvania, and Florida.

Florida's rejection "puts me in a quandary," says Bernd Wollschlaeger, MD, solo family physician at the Aventura Family Health Center in North Miami Beach, Florida. "The more of my patients who get insurance coverage, the better it is for me. But if they cannot get coverage, I have to make a very careful calculation on how many low-income patients I can see."


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