From the perspective of expanding and implementing near-universal coverage, the best news of the year was probably the reelection of President Obama, for whom health reform serves as the domestic policy centerpiece of his administration. The second-best bit of news was the Supreme Court’s decision to uphold the Affordable Care Act (ACA) in National Federation of Independent Business v. Sebelius. Had Mitt Romney become president, or had the Supreme Court struck down the individual mandate as unconstitutional, we probably would have witnessed the downfall of the ACA only two years after its historic passage.
Yet, quite possibly the worst news was also contained in that same Supreme Court ruling—the court’s decision that ACA’s Medicaid expansion is now effectively optional for the states. This further delays and complicates the already-delayed and already-complicated trajectory of health reform. Implementation of health reform will be a daunting challenge under any circumstances. This component of the Court’s decision made things even harder.
If Medicaid’s early history is any guide, states will eventually sign on. By actively assenting to such arrangements, skeptical governors may actually give the new Medicaid program greater legitimacy over the long-run. Moreover, the Supreme Court decision has had a salutatory impact on Washington politics within both parties. President Obama, for example, has quietly but wisely backed away from measures that would implicitly shift greater Medicaid burdens onto state governments.
Unfortunately, that same history suggests that this process will take a while, maybe until after President Obama leaves office. In the meanwhile, states enjoy new bargaining power to water down and obstruct key provisions of the new law. At best, millions of uninsured people in large states pledging not to participate in the Medicaid expansion will wait several more years for their basic needs to be met.
More generally, the Court’s decision bespeaks new legal challenges to the post-New Deal relationship between the states and the federal government. Until recently, most legal scholars believed that such basic matters of American federalism had been settled seventy years ago. Liberal and conservative legal scholars generally considered the legal challenges to ACA to be implausible. They were right on the law as it existed when they went to law school. They were wrong on the law as it exists today. The judicial philosophy reflected in this decision could have serious implications for Medicaid and other social policy efforts for decades to come.
Which brings me back to the presidential election. Over the next four years, we may see one or more new Supreme Court justices pledged to resist this rightward drift in constitutional jurisprudence. That’s among the best news of the year, too.
I will offer one final bit of good news. Somewhere between Nate Silver and Nostradamus resides my pre-election-day Incidental Economist column regarding the apparently intractable problem of financing health care for unauthorized residents of the United States:
ACA will leave millions of undocumented immigrants uninsured. This is an incredibly hard political and administrative challenge. At various moments, George W. Bush, John McCain, and other Republicans have worked with Democrats on immigration reform. These efforts have stalled. Lack of credible immigration enforcement and deep resistance within the Republican party base undermined possibilities for progress. . . .
I am nonetheless optimistic that some progress might be made, and for two reasons. The first is simple politics. If President Obama wins reelection, many Republican political professionals will rightly blame their loss on the antipathy their party attracts from huge and growing Latino constituencies across the country. . . .
I stand by this prediction. The 2012 election altered the roadmap of immigration policy. In doing so, it opened new possibilities for more humane health policy in this coming year.
Elections have consequences. This one especially did.