The most sweeping domestic legislative achievement in a generation is in the Supreme court this week, and all eyes are on the centerpiece of the health care reform law: the individual mandate.
First off, let's call the mandate what it really is: an individual responsibility requirement for the people who use health care (and that's just about everyone) to have coverage. If this part of the health care law falls, our broken health care system stays broken, millions continue to suffer, and we all bear the costs. The ranks of the uninsured will only continue to grow.
But even if the responsibility provision is upheld, there's another part of the law on trial that, if struck down, could have an equally devastating effect on our nation.
As part of its effort to extend coverage to all, including those who can't get private insurance, the Affordable Care Act (or ACA) requires states that are participating in the Medicaid program (and all of them currently are) to expand access to Medicaid to more low-income individuals as a condition of federal funding. The federal government is going to cover the costs -- funding 100% of the coverage initially and 90% in later years.
Under the Constitution, Congress has the power to place conditions on a state's receipt of federal funds. It's one of the main ways reforms of all sorts are nudged along to address national problems. You want federal highway money? Raise the state drinking age to 21.
Since the inception of Medicaid in 1965, Congress has offered to cover a portion of each participating state's Medicaid program so long as the state makes sure to cover certain people and services. States are given a great deal of flexibility to get federal funds to cover additional groups and services -- an option that states made aggressive use of over the years. That's the Medicaid model in a nutshell. If states don't want to provide the coverage to low-income people, they don't have to take the money.
The coverage requirements under Medicaid have continued to evolve over the past half century. The extension enacted as part of the ACA was designed to help close health coverage gaps in the growing population of families struggling with an historic poverty crisis. You no longer have to be "low-income plus" in order to qualify for Medicaid; low-income is enough.
As part of the overall challenge to the ACA, 26 state officials have challenged this extension, telling the Supreme Court that it is too "coercive." Is it significantly different from any of the previous expansions? Nope. So why now? Because this is political and involves throwing everything in the legal kitchen sink to strike down the law.
It's a reckless political game.
If the states prevail and the Medicaid expansion is declared unconstitutional, the Medicaid Program itself could be in jeopardy. This means immunizations for poor children, pregnancy services for women, nursing home and community based care services for elderly people and people with disabilities. But, that's not all. The implications go far beyond our health system to the very balance of power in our country.
Next on the chopping block will be dozens of federal investments based, like Medicaid, on Congress's power to incentivize the states to act locally to address national problems -- Congress' spending power.
America was built on a premise of shared values for a common good. That simple and cherished principle is now threatened by a political runaway train unleashed by a right-wing unhinged over the ACA.
Medicaid is a vital lifeline for over 50 million people in this country today, and under the ACA it will reach an additional 16 million poor people. It is crucial that the Justices not allow politics to undermine the sound constitutional underpinning of this law. Otherwise, millions living in poverty will be further devastated and, even worse, a crucial part of America's safety net might be lost for generations.