12/23/2012 09:33 am ET Updated Feb 20, 2013

Everyone in the Pool!

There is a classic Bill Cosby routine that features the punchline, "Everyone out of the pool!" There have been times recently when I have pictured the Obama Administration as a frustrated lifeguard with the opposite task, blowing a whistle and calling, "Everyone IN the pool!"

At its core, the Affordable Care Act, or "Obamacare," is an effort to improve healthcare coverage and lower individual health care costs by expanding the pool of insureds. More people in the pool means that "low-risk" (and therefore lower cost) individuals can offset costs associated with "high-risk" individuals, and that both sets of people can dodge the financial catastrophe of being un- or under-insured in the face of a medical crisis. (Medical expenses are the leading cause of bankruptcies in the country.)

Broader insurance coverage also means that more people are likely to get the preventive care and screening they need to keep chronic conditions like hypertension and heart disease in check before treatment costs spiral out of control. (Chronic illnesses, many of which are preventable, afflict fewer than 50% of the people in this country but account for 75% of our health care costs, which are in turn a small fraction of the related indirect costs, such as lost work days.)

Sometimes the costs of delayed health care are even higher. Just a few months ago, Nicholas Kristoff of the New York Times chronicled the untimely death of his uninsured college roommate from prostate cancer, and a few years ago the greater DC community was rocked by the death of a 12-year old boy whose untreated abscessed tooth led to a brain infection.

So it was heartening to see that the Obama Administration knows that this is no joke. In a much-anticipated decision, the Department of Health and Human Services announced that states cannot "partially" expand the Medicaid program and still hope for 100% federal funding. Everyone must be in the pool.

Up until now, Medicaid has provided health care coverage to low-income populations that Congress deemed to be especially vulnerable: children and their care-givers, as well as the elderly, sick, and people with disabilities. The federal government picks up, on average, 57% of the costs of the existing program; the remainder comes from the state. In the ACA, Congress expanded Medicaid coverage to include all low-income adults under 133% of the federal poverty level (making roughly $14,000 or less a year). Even better, it said the federal government would pick up the entire tab for the expanded coverage over the first few years, and then phase down their share but ultimately continuing to pay 90 percent.

In its decision on the ACA, the Supreme Court tweaked the law in one significant respect. Historically, if a state wanted to get federal money, it had to comply with a federal program in its entirety. A state couldn't raise its drinking age to, say, 18 and a half and ask for just a portion of federal highway funds in return. But in the case of the ACA, the Supreme Court said that HHS could not threaten to withhold all of a state's federal Medicaid funds just because a state decided not to implement the expansion. It was enough just to withhold the expansion funds.

As a result, some states argued that they should be allowed to partially comply with the expansion - leaving, for example, those making between $11,000 and $14,000 uninsured - but still be eligible for expansion funds.

Thweet! Everyone in the pool.

HHS's decision that Congress meant what it said--and that states do not get to pick and choose which parts of the law apply to them-- was the right one for many reasons. For starters, an estimated 17 million people could gain access to affordable, quality health care for the first time thanks to the expansion.

Second, at its best, Congress's role is to facilitate big solutions for big problems. This is at the heart of nearly every federal spending program, and it is certainly at the heart of the ACA. Allowing states to put only a toe in the water undermines the effort to address complex problems with comprehensive solutions.

Finally, HHS is refusing to indulge those who seek to play politics with people's lives. And lest you doubt this characterization, consider that states can drop the expansion at any time, pay nothing for the first three years of the expansion, and at no point will pay more than 10% of the expansion costs. In return, they get the chance to insure 17 million more people.

That's no laughing matter.