Where the Supreme Court Got It Wrong: Access for the Very Poor

It is hard to believe (at least in my mind) that anyone living in the United States today has not heard something from their neighbor, news, radio, etc. on Obamacare or the Affordable Care Act (ACA) as a result of last week’s ruling by the Supreme Court.  And to no surprise, there is roaring approval by some and steep condemnation from others.  Even on HealthFlock, we have bloggers on have differing opinions (pro vs. con).  While no one I can find believes that the the Affordable Care Act is perfect, I personally applaud the decision for what it does to address our “access” problems.

From my vantage point as a practice manager and operations leader working for a large health system, I am encouraged to see that the country is taking steps forward (through the ACA) to address our staggering problems around access to quality medical care, particularly for the poor.  Statistics routinely point to lack of affordability, availability, and acceptable of health services in our health system.  In Georgia, we see that 20% of people lack insurance.  Our state has one of the highest shortages of physicians in the country (we have only 200 physicians per 100,000 vs. a national average of 300 physicians per 100,000).  And, across the US, only 41.5% of primary care physicians are accepting new Medicaid patients.  While the Affordable Care Act doesn’t solve all of these problems, it dramatically improves the problem of affordability and allows for the average American to buy affordable insurance (even those with a pre-existing condition).

One clause that the Supreme Court did strike down, which I found very upsetting, was the automatic expansion of the federal minimum Medicaid eligibility level to all people with incomes up to 133 percent of the poverty line.  The Court ruled that this clause of the ACA that modifies the current Medicaid program did not constitute an expansion of the program but rather the creation of a new one.  Thus, if a state opted not to expand health coverage for those people whose incomes fell between 101 percent and 133 percent of the poverty line, then it would in effect jeopardize its existing federal Medicaid funding under this new system (essentially, an all-or-nothing scenario).  Thus, the Court argued that Congress could not compel the states to expand coverage to a higher minimum Medicaid eligibility level and sacrifice their existing position with their current Medicaid coverage.  (The Center for American Progress – CAP – does a better job than me explaining this in a recent write-up here.  The New York Times has a decent summary of it too.)

Whether you agree with the logic of the Supreme Court’s argument is less important in my viewpoint.  The bottom line of this specific ruling is that millions of Americans will be unable to pay for needed health services.  According to the CBO (Congressional Budget Office), expanding the federal minimum Medicaid eligibility level to all people with incomes up to 133 percent of the poverty line would provide 17 million Americans the ability to gain health coverage without a significant financial hardship.  Now, it won’t be near that number.  For instance, in Georgia according to CAP, 1.09 million people would get insurance if eligibility is expanded; without it, about 865,000 will not be eligible for tax credits to subsidize the cost of premiums.

It isn’t all doom and gloom.  The ACA provides tax credits to help for coverage for people with incomes up to 400 percent of the poverty line, or $43,420 for individuals and $88,200 for a family of four.  Even with this though, many Americans still can’t afford insurance.  What’s worse, many governors of states across the union (think Louisiana, Wisconsin, Florida, Iowa) have already indicated that they will not opt to expand coverage to cover more people who still cannot afford health coverage.   (This is hard in my mind to accept when the federal government is projected to pay the vast majority of the costs:  100 percent in 2014-2016 and transitioning to 90 percent after 2020.  Some even argue that the states will save money by expanding Medicaid.)

By any standard, last week’s ruling by the Supreme Court was a big win for addressing access problems, and that is something to celebrate.  However, the Supreme Court wasn’t all right; more work needs to be done to fix access for the very poor (including raising the minimum Medicaid eligibility level).  Now, Congress has an even higher burden as a result of the Court’s ruling to continue the hard work to fix our health system.  Hopefully for you and me and especially those in most need, such high expectations won’t be lost on them.

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