Those of us who are mere mortals have to take into account the consequences of our decisions. Not so for the U.S. Supreme Court.
While progressives cheered and conservatives railed against the Supreme Court's surprising health care decision, the real world consequences of the ruling for people who most need the protections of the new health law were decidedly mixed.
The big and good news is that the decision upheld the basic architecture of the Affordable Care Act, which protects people from the worst abuses of insurance companies, extends tax credits to people (living above the poverty line) to defray the cost of health insurance, and begins to make the delivery of health care efficient and less costly. Tens of thousands of Americans live longer as a result of improved access to low-cost preventive services and better benefits. Insurance companies that had previously thrived on profits from denied claims will now be accountable for their actions and will be forced to change their ways.
The cruel irony though is that by allowing states to opt out of taking federal dollars to expand their Medicaid programs, the Supreme Court decision could result in the poorest Americans in the poorest states in the nation excluded from any health coverage under the Affordable Care Act. That is because the way the health law was designed, Americans in families earning below the poverty line are meant to be covered through their state Medicaid programs, not through federal tax credits.
If a state chooses not to set up a state health care exchange or market place, people in the state who are uninsured and earning above the poverty line can still get tax credits to purchase health coverage. Not so for people living in poverty. People with earnings below the poverty line -- $23,050 annually for a family of four -- would be left out in the cold, forced to continue relying on emergency rooms and community clinics for their care.
If all of the states that filed suit against the Affordable Care Act refused to accept federal Medicaid dollars to expand their programs, as many as 8.5 million of the most indigent people in the country would be left out of the basic protections of the new law. The people most at-risk are in a set of states like Texas, Louisiana, South Carolina and Florida that have the greatest racial and economic inequality and deepest poverty in the country. Governors from these states have made statements planning to refuse Medicaid funding.
Refusal of this funding doesn't help state finances -- it just sets them further back. The federal government picks up the full cost of expanding coverage for three years, and then 90 percent after that. With the tax revenue and jobs created by federal dollars, participating states come out way ahead. Refusing the deal means putting ideology ahead of both the health needs of people in the state and the state economy.
Politically, governors in states that refuse federal dollars will find themselves up against a coalition of powerful interests that include hospitals and small business groups. That is because, under the new health care law, hospitals will gradually lose the federal funds they currently receive to defray the costs of treating uninsured patients. If a state refuses to extend coverage to indigent residents, hospitals are still on the hook to admit them, but they don't get the funding to pay the costs. Same problem for small businesses in refusal states; they get costs shifted onto their health insurance bills for the system-wide costs of covering the uninsured, rather than having those costs picked up by Medicaid.
Over the next two years there will be a lot of organizing to be done in the refusal states to engage and connect low-income families that have the most at stake with hospital, small business and faith groups to build the political will for Medicaid expansion.
Ultimately whether a state is willing to spend pennies to buy a dollar's worth of health coverage for its poorest citizens is a moral question. Last week faith leaders from PICO National Network in nine states wrote their state governors imploring them to do the right thing in extending health coverage to people living below poverty.
Our shared religious traditions teach us that our common priority must be to care for the poor and vulnerable. We are called to stand in the breach and advocate for those whose voices have been diminished. We believe that our state must help protect the health of those who are in need, especially struggling families, the elderly, and the disabled.
It can easily get lost in the political posturing but the reality is that lives are at stake in the choices that states make in their health care policy.
Ultimately we may not all have to face the practical or political consequences of our decisions, but none of us can avoid the moral consequences.