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Because the authors of the Affordable Care Act saw no issue with the expansion of Medicaid and presumably found it constitutional, they wrote the exchange subsidies as affecting everyone above the rate of Medicaid, specifically about the federal poverty level (FPL). But what about people who make below the poverty level? They may be ineligible for subsidies, but that’s OK, because they can always hook up with Medicaid, which is now expanded to 133% FPL. However, if the part of the ruling reducing the leverage for the federal government to extend this Medicaid expansion to the states winds up in big fights among red-state governors, those under 100% FPL could find themselves out of luck:
I said this morning that people would go into the insurance exchanges where they’ll collect subsidies to be able to afford insurance. This is true for people earning between 100% and 133% of the Federal Poverty Line but it looks like there’s a fair chance that people will be ineligible for tax credits if they’re earning less than 100 percent of the FPL. Most such people in most states will, I repeat, end up covered by Medicaid anyway because the carrot is enticing. But some of them will end up with hardship waivers and no insurance.
Most states where this would come into play, i.e. red states, currently have Medicaid programs that fall far short of 100% of the FPL. For example, in Texas, a working parent is ineligible for Medicaid above 27% of FPL. So if Rick Perry in Texas decides not to accept the Medicaid expansion, all working parents between 27% and 100% of FPL have a hardship exemption, so they don’t have to buy insurance, but they have no way to capture subsidies for the purchase of insurance. So they’ll be locked into remaining uninsured.
I’d like to see some analysis on the vulnerabilities this will provide. But it’s not the case that the poor will have the option of either Medicaid or the exchanges. They might end up out of luck. This outcome, of course, all depends on whether governors reject the Medicaid expansion in favor of keeping their old Medicaid systems in place.
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But Dday, what is the number that you say is non-trivial? Is there a link to the underlying data that we should start studying?
For example, for your Texas example, are you saying that if Rick-Secede-Perry opts out of Medicaid expansion, persons with incomes from zero dollars to 27% of the federal poverty level would be s**t outta luck (SOL)? How many persons are in that poverty donut hole?
I need to do a fairly labor-intensive analysis to figure that out. But the initial stat for just Texas was that 1.4 million people would benefit from the Medicaid expansion to 133% FPL. Assuming there are plenty of people between 100% and 133%, you could be talking about 700,000-1 million in Texas alone. And the people out of luck would be from 27% to 100%, not 0 to 27%.
oops, thanks, I switched it. So households with incomes of 27% of federal poverty level up to full poverty level would number, roughly, 0.7 million to 1.0 million, those from full poverty level up to 133% of poverty level would number roughly another 0.4 million, for a rough total of up to 1.4 million.
Are any of those folks currently covered by any health insurance? All of their kids are covered under S-CHIP, right?
Even if their kids are covered, if those adults are not covered they will gradually become sicker, burden the disproportionate-share hospitals (DSHes) even further, and push more red ink into city and county budgets, right?
Can the DSHes find funding to overcome the nullification governors refusals to accept Medicaid expansion? Is there any other end run around those refusenik governors?
It just bugs me to no end that the corporate press is treating one line of Roberts’s solo opinion as if he spoke for the Court majority:
That from the usually more accurate New York Times reporter Robert Pear, who is a true star reporter when it comes to health care. What one Justice says is not law, and I don’t know how to break through this rapidly-congealing frame that the “dragooning” line (and all of part IV-A in which Roberts used that line) was not joined by any of the other eight Justices.
Robert Pear confirms Dday’s analysis:
Being insured is irrelevant if you still cant afford the actual health care
Gosh, it seems like it may be a problem to strike down a critical provision of a complicated law, and then ignore the severability clause and try to keep the rest of the law intact.
But it shouldn’t be a problem. Congress can just vote an amendment into place to fix the problem. They still have the votes for this wildly popular legislative initiative, right? They wouldn’t be afraid to cast a vote in an election year?
As for how the feds could get around the problem that the law calls the states’ involvement voluntary, but its proponents are shocked, shocked, to find that some states may opt out, the solution is obvious. Quit shoving the problem onto the states. Figure out what the goodies will cost, fund them with openly avowed federal taxes, and win public support honestly. Or resign yourself to losing the next election if honesty doesn’t pan out for you.
That’s why I did not care one way or the other about this law from the beginning. It was never about lower income people getting insurance.
In my state, subsidies will be minimal, and it will be a tossup between the cost of the fine (… tax… whatever) and the cost of the premium. If the insurance policy is cheap enough I might as well pay to at least have a card in my pocket. Even then I am sure the policy will be practically useless if I can’t afford the deductible and co-pays. I will be able to get care one time and then be bankrupt when the rest of the bills come through.
Will the hospital be required to admit you even if you have not been able to pay the bills from the last time?
I will be paying out money for nothing except to give the administration credit for “insuring the uninsured”.
I learned at a health care meeting last week that, regardless of SCOTUS’s actions, Oregon’s health care insurance/delivery reform will proceed apace, since our current overhaul is based on state laws passed in 2001 and 2009. We aren’t really affected except to the extent of the waivers we get from the Feds to go our own way.
I did learn that the insurance companies,hospitals, and doctors’ groups have lobbyists meeting every day they can with the policy-makers, so that Oregon citizens need to work very hard to make our voices heard at advisory group meetings, board meetings, and patients’ groups meetings. Unless we ALL work harder at getting our opinions in front of policy-makers and bureaucrats, health care delivery/insurance will look very much the way the BIG stakeholders want it to, since they are the people who are being heard now, because they can afford full-time lobbyists.
The bureaucrats and policy-makers were practically begging citizens to be more pro-active, because they are only hearing from Big This and Big That, not regular people.
It’s hard work, impoverishing the poor.
Republicans and the true believers will not rest until they see people literally dying in the streets.
While this ruling has been declared a victory for the people, it should be noted that the biggest winners are big Pharma and the health insurers. Make no mistake, their interests are well represented in the Affordable Care Act.
Dear Obama, the Supreme Court, Democrat and Republican Congress:
We the people have been mandated by you to buy health insurance from private corporations. We are already paying outrageous premiums which are sure to go up.
We cannot afford these outrageous premiums.
So, we the people demand that said private health insurance companies cap the pay of all employees, up to and including the CEOS to $200,000 and less.
No more stock options.
No more private jets.
No more overseas junkets.
No more golden parachutes.
No more making millionaires and billionaires from our mandated premiums.
And if you don’t think we have the power to demand this and get it. Just watch.
Signed,
The Mandated
So if ACA with Medicaid expansion still leaves 20 million not covered, what is the number potential if large numbers of states opt out?
1. Does today’s ruling help or hurt Vermont’s single payer legislation
2. What if people just refuse to comply? No insurance, won’t pay your fine or ‘tax’