The Affordable Care Act has become embedded in the national safety net after a third Supreme Court decision upholding its constitutionality. And in the wake of that ruling, the Biden administration and various states are seeking to upgrade Medicaid, the federal-state program that provides medical coverage for low-income Americans and the disabled.
Several states are taking advantage of a provision in the $1.9 trillion American Rescue Plan Act (ARPA) signed by President Biden in March that enables Medicaid to offer a year of health coverage for new mothers instead of the present 60 days.
Although this provision has been overshadowed by other parts of the rescue plan, it’s a big deal, as Biden might say. The United States has a high infant mortality rate for a developed nation, 5.7 deaths per 1,000 births. That translates into more than 22,000 infants dying every year. Medicaid covers nearly half of all U.S. births, and experts say that improved neonatal care will save lives.
Medicaid Growing at Rapid Rate
Overall, Medicaid (known as Medi-Cal in California) now insures nearly one in four Americans and is growing faster than any U.S. safety-net program. Enrollment in Medicaid and the related Children’s Health Insurance Program increased from 71.3 million in February 2020, at the beginning of the pandemic, to 80.5 million in January of this year, according to an analysis of data by the Kaiser Family Foundation (KFF).
“The pandemic has forced states to take a look at their programs, and there’s been an effort to improve access,” said Emily Blanford, a Medicaid specialist with the National Conference of State Legislatures.
One useful provision of ARPA will provide $12 billion for Medicaid long-term services. This will enable millions of older adults to receive health services in their homes and communities, rather than in nursing homes and other institutions. Forty-two states have applied for funding under this program.
ARPA also provides additional Medicaid money to states to establish mobile crisis services for people facing mental health or substance abuse emergencies. “There was a lot of discussion [of this] during the Trump administration, but not the capital to do it,” Kate McEvoy, director of Connecticut’s Medicaid program, told KFF.
On another front, California has budgeted $1.3 billion to extend health insurance to unauthorized immigrants 50 and over. The state estimates this will cover 175,000 adults in 2022. Since 2016, the Golden State has provided health care insurance for the children of unauthorized immigrants up to the age of 18. Five other states — Illinois, Massachusetts, New York, Oregon and Washington — and the District of Columbia also offer health insurance for these children up to age 18. Sixteen states provide prenatal care to undocumented pregnant women.
Courts Rebuff Republican ACA Challenges
All of these states have Democratic-controlled legislatures and — with the notable exception of Republican Charlie Baker in Massachusetts — Democratic governors. That is unsurprising. ARPA passed on mostly a party-line vote, as did the Affordable Care Act, signed into law in 2010 by President Obama.
But the exchanges for purchasing health insurance did not come into being until 2014, and Republicans effectively opposed Obamacare in the interim between passage of the law and creation of the exchanges. Demonizing the program as a step toward socialized medicine, they took control of Congress and a majority of state legislative chambers in the 2010 midterm elections. But Republicans have fared poorly since the ACA took full effect; GOP efforts to overturn Obamacare failed three times in Congress and also three times in the Supreme Court.
The high court’s acceptance of Obamacare has come by steadily widening margins: 5-4 in 2012, 6-3 in 2015 and 7-2 in June of this year, when even Clarence Thomas, the court’s most conservative justice, joined in ratifying the law.
In the latest challenge, the attorneys general of Texas and 17 other Republican states claimed that the statute became unconstitutional when Congress in 2017 eliminated the financial penalty for Americans who did not buy health insurance. The court’s majority ignored this argument, ruling that the states that had brought the lawsuit lacked standing to sue because they had not been harmed by the ACA.
ACA Now More Popular Than Ever
In the wake of the court’s decision, most Republicans have abandoned the effort to kill the Affordable Care Act. GOP congressional leaders criticized the ruling but did not renew previous calls to repeal and replace Obamacare.
This may reflect the increased popularity of the law. A May poll by the Kaiser Family Foundation found that those surveyed favored the ACA by a 53%-35% margin.
Obamacare has three goals: making health care insurance affordable for more people, expanding Medicaid, and supporting research and development of innovative medical care that might lower the overall costs of U.S. health care. It has partially succeeded on the first two goals, while the third has been largely delayed by the COVID-19 pandemic.
As of June 15, 31 million Americans had obtained ACA health care coverage, according to the Department of Health and Human Services. HHS data identified 11.3 million Americans as having obtained coverage through the exchanges and 14.8 million enrolled in Medicaid due to the ACA’s eligibility expansion. Thirty-eight states and the District of Columbia have expanded Medicaid to provide health insurance to families and individuals with income up to 138% above the poverty line. (The federal poverty line is $12,880 for an individual and $31,040 for a family of five.)
Single adults were covered in the expansion for the first time.
Twelve Republican-controlled states, including Texas and Florida, have declined to expand Medicaid to ACA levels despite generous federal subsidies if they do so. This has left about 2 million people in these states without health insurance.
Medicaid, Obamacare Still Face Uncertain Future
Going forward, both Medicaid and Obamacare face uncertainties as the nation emerges from the pandemic into a changing health care landscape.
Medicaid was created in 1965 by the same law that, at the urging of President Lyndon B. Johnson, established Medicare, the federal health insurance program for the nation’s elderly. Unlike Medicare, however, Medicaid was voluntary for the states, which shared the program costs. Arizona, the last state to establish a Medicaid program, did not do so until 1982.
Forty-three states reduced Medicaid benefits during the Great Recession of December 2007 to June 2009, which imposed heavy burdens on state and local government. When the coronavirus pandemic struck in 2020, state budget analysts feared a repetition of the Great Recession scenario, but federal financial payments to individuals and extended unemployment benefits kept Medicaid growth lower than expected. Congress helped additionally by increasing the federal share of Medicaid costs.
Nonetheless, total Medicaid costs for states exceed $600 billion, and states might need to reduce benefits during the next economic downturn.
When it comes to the Affordable Care Act, the present upgrades may prove even more fleeting. Even the least expensive insurance plans available on the ACA were beyond the financial reach of millions of Americans who do not qualify for a subsidy. The Biden administration addressed this problem in ARPA by extending eligibility for ACA health insurance subsidies to people with incomes over 400% of the poverty level. But the provision lasts only two years, retroactive to Jan. 1, 2021.
Republican perception of the ACA as a partisan program remains its Achilles’ heel. To maintain the health insurance upgrades made possible by the election of Biden and the passage of ARPA, Democrats will need to either persuade some Republicans of their merits or win the congressional midterm elections of 2022.
Accomplishing either of these objectives could prove a tall order.
This article first appeared on State Net Capitol Journal.