But because the Affordable Care Act significantly strengthened the government’s role while coming close to achieving the progressive movement’s long-standing goal of making health insurance coverage universal, conservative judges were not willing to give up easily. So a multitude of lower court rulings were issued—some favorable to the act and others not—before today’s affirmation written by Chief Justice John Roberts that that the legislation is constitutional after all. The mandate amounts to a tax, and Congress can raise taxes. Just as us non-judges thought from the beginning.
The one significant glitch was the Court’s decision that any states that opt out of expanding Medicaid to comply with new requirements under the act should not be at risk of losing federal funding for their existing Medicaid program. That provision of the law was intended to ensure that every state would extend Medicaid coverage to all residents up to 133 percent of the poverty line. Even without that threat, however, it is likely that only the most anti-government states will expand Medicaid. That’s because the federal government is paying the full cost of new enrollees for the first three years of implementation, and then more than 90 percent of the cost thereafter. That is substantially more than matching rates ranging from 50 percent to 83 percent for existing Medicaid beneficiaries. In other words, Medicaid expansion is a great deal for the states.
No doubt some hard-right governors in states like Texas will ostentatiously threaten not to expand Medicaid, as an expression of their hostility toward the federal government. But those governors will confront enormous pressure from local hospitals, doctors, and the medical industry generally, who will lose many millions of dollars that would otherwise be available from the federal government. Uninsured residents who normally don’t have much political clout could also be expected to organize against governors who block their access to insurance coverage.
Many conservative governors also vowed not to accept stimulus money from the federal government after the financial collapse, but in the end they all did.
Now it’s only a matter of implementing the Affordable Care Act, whose main provisions begin to take effect in 2014. No doubt that process will be prolonged, tortured, and cliff-hanging.