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Subscribe to RSSFormer Medicaid and Medicare director Donald Berwick says few states were likely to reject the Medicaid funds despite the court's decision.
Updated at 7:04 p.m. ET: Now that the Supreme Court has upheld President Barack Obama's health care initiative, will Congress have to rewrite it from scratch?
It's not a paradoxical question. The court signed off on nearly all of the Patient Protection and Affordable Care Act, but it struck down one provision, and in doing so — whether it knew it or not — it may have put the poorest Americans at the greatest risk of being left without any health insurance.
Chief Justice John Roberts said as part of the 5-4 decision that states can't be penalized for refusing to join the law's expansion of Medicaid eligibility. Health law experts said that had the practical effect of flipping an all but mandatory program into one a state can choose not to join.
Here's the problem: The ACA creates state health insurance "exchanges," providing tax credits to eligible residents to buy affordable, state-certified health insurance. But the poorest Americans aren't in that eligible pool, because the law assumes they'll be covered by the expansion of Medicaid, which is no longer a given.
In states that reject the expansion, poor residents could be left without either form of coverage — as many as 15 million if all 50 states opt out, a circumstance that former Medicaid director Donald Berwick said was highly unlikely.
The White House didn't address the issue in a long Q&A it issued on the court's decision. The statement touted every provision of the act but one: Medicaid expansion.
Medicaid currently covers only some low-income people, primarily parents with children, pregnant women, people with severe disabilities and senior citizens. Adults without disabilities or children, in other words, aren't generally covered. That's the group the Medicaid expansion was supposed to help the most.
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If their states opt out, young working adults below the poverty line could be in a Catch-22, because "they may not get Medicaid, and they may not be eligible to purchase insurance through the exchange," said Christina S. Ho of the Rutgers University School of Law, who was a member of President Bill Clinton's Domestic Policy Council.
It works this way:
The insurance tax credits are targeted at people with incomes between 100 percent and 400 percent of the poverty line as determined by the U.S. Census Bureau. Congress sought to compel the states to cover everyone under the line through Medicaid.
The federal government promised to fully cover all expenses for the expanded coverage before eventually pulling back to cover 90 percent after a few years. The states would have to pick up the extra 10 percent eventually.
States aren't required to take part, but if they don't, the law as enacted would have turned off the flow of all Medicaid funding from Washington.
That enforcement mechanism is what the court invalidated Thursday, meaning there's no penalty for a state that says, "Thanks, but no thanks."
Twitter reactions to the ruling
Because states haven't had time to consider yet whether they will opt in or out. it's difficult to say how many people could be affected.
But about half of the nearly 50 million uninsured Americans have incomes below the new eligibility thresholds, according to the latest report, in October, from the Kaiser Commission on Medicaid and the Uninsured. And about 6 in 10 of them are adults without dependent children — the primary beneficiaries of the program's expansion.
If you do the math, roughly 15 million Americans could be in the newly created gray area. In 2010, when the act was passed, the Commonwealth Fund, an independent health care policy foundation, similarly calculated that the Medicaid expansion would benefit 12 million of the 15 million uninsured Americans under the poverty line.
Donald Berwick, former head of the Centers for Medicare and Medicaid Services, which administers the two programs, said few states were likely to take that risk.
"Those people are still living in your state, They're still poor. They're going to come to your emergency room. They're going to be operated on, and they're going to have diseases that get worse, and you're going to have to pay for that. That will come from the state — free care pools and charity in the state," Berwick said in an interview on MSNBC-TV.
"I think what's going to happen is the states are going to be under pressure from providers of care who say: 'Why are you leaving this money on the table? Let's join in with the federal dollars.'"
But Judy Solomon, vice president for health policy at the nonpartisan Center on Budget and Policy Priorities, agreed with Ho that the decision means low-income adults could lose the promise of Medicaid coverage "even while people with somewhat higher incomes will be eligible for premium tax credits."
Writing on the center's policy blog, Solomon said: "The poorest adults — primarily parents and other adults working for low wages — will be left out in the cold."
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Leave a Comment:
This headline alone is extremely misleading.
Anyone who knows anything about the Affordable Care Act knows that medicaid will be expanding. In order to qualify for medicaid now, you need to be below the poverty level. It will increase to 133% in the near future.
For those above that level, but still in poor financial shape, there will be subsidies to help you pay your insurance premium.
This has all turned into one big lie perpetrated by the rightwing nut jobs. It's just lie after lie and they weren't against it when Gingrich had proposed it several years ago. They just didn't want to see President Obama and the Democratic party be the ones who accomplish such a huge feat.
Obama/Biden 2012
Poor get it free and non rich get a gov't subsidy? Go take another hit on that crack pipe. Your going to jail
This is total crap, so this is the first TAX that you can actually go to jail for for just being alive. We need to change this now. What about all the poverty level people? Was this a way to put them all in jail. Everyone is required to have the healthcare so everyone is required to pay the TAX.
Jail is not part of this and if you were informed, you'd already know that.
If you're alive, you'll more then likely need healthcare at some point in your lives. Who is going to pay for it the way our current system is set up now?
That's right. The people who are responsible and carry insurance along with the counties. They're the ones picking up your tab at the moment. Sad that people will now have to be responsible for themselves, isn't it?
Vood - you are amazingly ignorant, it is almost funny but more sad. All day long for starters the news is saying you can't go to jail and yet you have the audacity to post it...that is stupid.
John it's not just the president, it's the WHOLE GROUP. As a WHOLE they are disfunctual.
It's like letting a bunch of 8 year olds run the country.
I KNOW YOU ARE BUT WHAT AM I stupid my way or nothing attitude......ALL OF EM
It's spelled, "Dysfunctional". You're right. Since the Reagan Regime, the Right have moved farther and farther toward insanity. Their propoganda is second to none.
Just remember liberals and Democrats, you asked for this against the American taxpayers, they will remember for a long time.
U.S. will pay for half of all health care costs by 2020 - July 28, 2011
"By 2020, nearly 30 million additional people are expected to have health insurance because of reform.
Over the 10-year period, the report showed that the biggest annual jump in health care spending will happen in 2014 when health reform is fully implemented.
CMS estimates that in 2014 about 23 million uninsured consumers will gain access to health insurance, mainly through government programs such as Medicaid and through the creation of federal and state-funded health insurance exchanges.
As a result, the government expects Medicaid spending to surge 20% in 2014 and private health insurance spending to increase 9.4%.
Norwalk said the estimated sharp surge in Medicaid spending just in one year, is very concerning given that states are already struggling with their budgets.
As millions more gain access to health insurance, the government expects spending on prescription drugs, physician and hospital services to increase as well.
CMS expects prescription drug spending to jump by 10.7% in 2014 and to account for 11% of national health spending by 2020. Spending on physician and clinical services is forecast to rise by 8.9% by 2014, representing 19% of overall health care spending."
http://money.cnn.com/2011/07/28/news/economy/healthcare_spending_forecast/index.htm?source=cnn_bin&hpt=hp_bn3
P.S. Keep in mind these are even the government released numbers, the reality will be much worse.
Have you seen the recent polls? 50% of the Americans want this. Of the 50% who are not in favor of this, 13% of those people would've liked to see the Affordable Care Act go farther.
According to my calculations, that leaves 37% of the population who is deadset against this. Can you say, "Tea Partiers?"
pjm -
when you say US will pay half of health care cost by 2020 are you talking about the government or people in the US?
Where exactly did you get half? I must be missing that information somewhere.
More liberal lies. People would rather have it repealed than as is, two to one. 50% would be happy with part of it, and NOT the mandate/tax.
Nice try.
If most of you didn't have a public school you would understand that an immense empire like the Soviet Union collapsed not from a military disadvantage but from the enormous weight of government bureaucracy. We are headed in that same direction.
The Roman Empire is also another good example.
FREEDOM: The Soviets could not keep up with their "Military Industrial Complex" kind of like what Bush and Cheney did, pissing away god knows how many billions. But you're cool with that, right? That's money well spent. Do me a favor, would you, give me a call when you find all those WMD's that cost the lives of 4500 troops and 25,000 wounded. Iraq was a real bargain wasn't it? But god forbid that the richest nation on earth should see to it that it's citizens receive decent health care.
8 years of Bush proved once and for all that Republicans are no fiscal conservatives, they merely spend the money on things which do little good for the average citizen. I'm not interested in your preaching, the Right does not have a leg to stand on.
The Soviets collapsed from the enormous weight of government bureaucracy as a result primarily because of defense spending.
....first....if this a$$hat remains as Pickpocket In Chief....it will be impossible for our economy to ever improve. That said...with the choice between buying healthcare for myself, wife (we're both self employed) and our daughter...at a nearly $12,000/year cost....and getting "fined"...ooops...TAXED...at a lower rate...I choose the tax...and being able to make my mortgage payment.
OPUS: You don't sound all that grateful. I presume you are referring to Obama, not chief justice Roberts. So if I understand you correctly, you're greatful for the opportunity to finally get affordable insurance but you think Obama is a schmuck regardless. Do I have that right???
And you blame the economy on Obama??? Funny, I thought the worst economic crash since the Great Depression (also brought to us courtesy of the GOP) occurred on Dubya's watch?
Our economy HAS been improving. The regime in control of the previous eight years ran this country into the ground. How easily some forget.
Opus - the cost of employer unsubsidized health insurance before the HCR for a family of three was about $800 to $1200/month so if the cost has not changed for you what are you bitching about?
FYI: my cost of health insurance for two before the HCR (3 years ago) was $700/month today it is $700/month. Without HCR it would have gone up 3 to 6% by now.
Last getting penalized does not provide you coverage.
More liberal lies. Democrats crashed the economy after they took over congress. They inherited 4.6% unemployment and a booming economy and destroyed it. Six years later and unemployment is still double what they inherited. Bush couldn't spend a dime without democrat congress approval.
Nice try.
Honestly, America needs to just completely rip off Canada's basic health care framework, and all of their problems will go away. It's paid for mostly through income tax, so those who earn less will pay less, which should satisfy all of those carrying on about not being able to afford another tax on a low income.
When this whole issue first arose, I couldn't even believe that so many Americans were so vehemently opposed to universal health care. This helpful chart on Wikipedia speaks for itself:
#Comparison_to_other_countries
We spend less per capita on health care, and yet we get more for our money. 'Nuff said.
KEVIN: You underestimate the forces of ignorance and darkness in the GOP. Hate is what they do best. It's how they get working class people to slit their own throats, voting against their self interests. It's worked for many decades from the Red Scare of the 1950s, through Viet Nam, The Cold War, etc. Amazing how they rope so many people in.
Kevin, your country is doing this right. You take care of your own and everyone is allowed the liberty of getting good healthcare.
Unfortunately, it hasn't been that way in our country and hopefully, this new law will remedy that.
Keven, you do realize your own health minister said your system is unsustainable don't you?
And nobody's buying the left wing fascist propaganda, so get over it. You would think 2010 would have given you a hint.
I'm wondering.......where is the money coming from and how soon does the Dollar crash? Will this spending ever end? What happens if the dollar crashes? Do we eat our health insurance ?
HILL: Geez, I guess you should have worried about that when Dubya dragged us into two UNFUNDED WARS as well as an UNFUNDED drug plan, while simultaneously slashing taxes, especially for the rich. And now you want to know why we're broke??? And the GOP wants even bigger tax cuts now???
Sorry, you are a day late and many, many dollars short. Besides, that great genius Dick Cheney said "Deficits don't matter".
Intrepid1
When that occurred the democrats controlled congress and allow him to do it. You should really get informed before you open your mouth.
Plus you failed to mention that Obama never repealed the Bush tax cuts to the rich like he said he was going to do, but it doesn't end there.
Obama never even propsoed his tax reform when the democrats had control of congress.
Blaming Bush for this country's debt just shows you are just another brain washed Obama supporter who refuses to get informed.
The data shows that the our failing economy actually started with Reagan and voodoo economics (trickle down). Had all Republican presidents starting with Reagan balanced their budgets and the Democrats did exactly what they did the ND as a % of GDP would be about 20% now and not 100+%. Mr. Obama had no choice but to spend to keep us out of a depression....lesson learned from 1929.
That's a pathetic lie. Under Carter the dollar lost half it's value. Reagan cleaned up the mess. He was so successful he won the biggest landslide in history, carrying 49 states his 2nd term.
And it was democrats that destroyed the economy after they took over congress, this disaster is on their watch.
Facts trump libral lies every time.
red state or blue state? live or die? WAKEUPAMERICA.
How profound.
good!
There are roughly sixteen million farm workers in the U. S. 98% of them came to the U. S. illegally. The domestic farm workers they replaced arn't worrying about healthcare like they are worrying about employment of which there isn't any for them. The decision on Monday to stick a knife in the backs of Americans via the dismemberment of the Arizona HB 1070 will do more to secure the poverty of Americans of all colors, creeds, and national origions than this health care decision. When you don't have any job to pay the deductable you don't care what the government will or won't pay.
@pjam09 The whole economy will be toast if Obamacare is allowed to remain in effect: Dude dont make me laugh ok.
Tax payers already foot the bill for millions of people who go on Medicaid/Medicare because no preventive medicine exsist at all. What you call Obamacare actually allows working class folks like myself to buy affordable healthcare that I co-pay which prevents my disability and allows me to help foot the bill for my family instead of automatically having you pay it thru tax dollars.
But your too busy chewing your ankle off searching for socialist agenda's to realize, that no small bussiness owner offers health insurance above work/comp.
That HMO/PPO are only offered in the larger local corporations and work/comp litigation takes years to accomplish, hey if you can't walk the walk don't talk the talk.
It will bankrupt us, get over it.
We have a debt crisis in this country and a national debt that is reaching $16 trillion. We have a President spending money like it grows on trees.
Do the math. This country is going bankrupt. Last August was a warning sign that things aren't good, yet Obama hasn't heeded the warning.
This country's future is limited.
I am a bit confused by this article. Suppose a person of limited means dwells in a state where he is not covered by Medicaid. Does this mean that under the Federal Affordable Care Act he will be required to buy insurance or pay a penalty?
I believe you will be required to buy a policy, but there is nothing in the law that says that policy will cover your medical expenses. The policy could have an accrued amount of medical expenses you need to reach like $50,000.00/year before they start paying out on the policy.
The health care law is a mess. If only Obama would have had an open dialogue with Americans about this, and if we could have had a discussion on this...perhaps a decent law could have been crafted.
Instead we have hundreds of pages of a poorly thought out law that down not serve any of us well. I have higher taxes coming my way, and higher premiums. I lost. I am sure others did too.
T-Rex:
There were many open dialogues unfortunately drowned out by the loud misinformation machine on the right. I had the legislation, which was available to all, 2 weeks before it was passed. While I may not have read it in detail I scanned through it to get a good sense of what it was all about.
Now our congress folks have better access to this legislation, they all have an army of lawyers and clerks whose job is to read this stuff and help the congress man understand it. If you are told that they did not have time to read it it is only because they did not want to read it and you should fire them for being lazy.
It is not perfect but I would not call it poor if you have not read it. It is not easy to read but then most legislation's are not but just because it is written in legalese does not make it worthless. It is a good start and I hope once we get over this shock both side will work to make it better.
More pathetic liberal lies. This whole thing was created behind closed doors with not even republicans invited much less the public. Pelosi even said we had to pass it to know what's in it. It's so poorly written nobody knows what it will be like when it's implemented, it's all left for the leach bureaucracies to flesh out. Every time a new estimate is made the cost goes up by hundreds of billions.
The Medicaid portion of the law has a bigger problem. There is a growing shortage of primary care physicians in the country, and doctors do not have to accept Medicaid patients. Why would they take on a patient and lose money when they can add patients with better insurance reimbursement amounts?? They won't. That means many more folks will have Medicaid, but they will still have to go to hospital emergency rooms for treatment, just as they do now. Of course the hospitals will get a big benefit because they will get the Medicaid insurance payments instead of nothing. And the big Pharma companies will get the benefit of additional prescription drug sales. But those ER waiting lines will simply get longer. What a hoot.
If the Obama Bill is what I think is said as tax may be like major hospitals years ago did. My 50 year old daughter was born as a special needs child. In Los Angeles area she was treated at UCLA Hospital, Danny Thomas Hospital, Children's hospital and a regular hospital. She had a blocked heart surgery, and other's. What they charged us was all out go bills were added together and then our income. We paid on that basic, I remember we never paid over $5.00 at any of those hospital's. If this is how he plans it how can anyone gripe. Be a Romney and cry for donations?
meatly
If you think Obamacare works that way, you are grossly misinformed.
Okay, I am waiting for some idiot coming on saying "should of let her die" She is an amazing lady now, has full time work and care. Intelligent too.
I have mine; so I don't care.
Get a job.
I think it was known that by allowing states to not have to participate in increased medicaid insurance for the poor an automatic loophole was created.
To me it is pretty obvious, because here is the actual fact: government is running out of money, states are running out of money. But even a health care law cannot change those facts.
One thing is also quite apparent: While we do not have control over some illnesses, now more than ever it pays to research your own health. Now more than ever it pays to adopt a healthy life style.
One has to recognize that many of our ailments are created from the wrong food choices, increases in weight, sedentary lifestyles and so much more.
Having taken most of my own health issues into my own hands and having switched from regular medicines to natural supplements has enabled me so far to only take one prescription medicine.
One can never stand still when it comes to one's health. I am a firm believer that many procedures and treatments, including medicines actually result in increased health issues for many people. Rather strangely was the fact that I recognized such issues when I attempted to free myself from regular "modern" medical treatments and ventured into the realm of natural treatment choices.
One thing was instantly clear: Several "illnesses" , since having stopped taking the advice of "medical doctors", and stopped taking medicines have completely disappeared.
Not to say that people can completely forgo some treatments, but I think to a large degree people can affect their own health, can increase their health, and perhaps by staying away from doctors and believing everything they say actually live a healthier life.
I know, it sounds strange, but it's true.
The scare tactics from the right wing losers are hilarious. It is this party's mantra to preach everyone to take responsibility and pay up for things-no freeloaders. Well, in the ACA when the freeloaders are subject to penalties- which the SCOTUS wants to call tax- look at the commotion they are creating. This same healthcare experiment and the mandate (tax) was put in place by Mittens in Massachusetts, repubs didn't have problem then. It was called a very successful expt. Now when you do that for America in a constitutional way, its a problem? Hypocrisy thy name is Republicans. They have vowed to not allow anyone in America to progress or do well. They are not worried about creating jobs for Americans but only in taking Obama's job. How pathetic!
More lies. Mass wanted it, the US did not, two to one. Romney listens to the will of the people, Obama pisses on it. What part of shellacking do you not understand?
If we just stopped invading other countries and dropping bombs on people and sailing huge carriers and submarines around the world, we would have the money to take care of our people at home. Imagine that, using our tax money for helping our own citizens, instead of causing death and destruction to other people....
YANK: But it's so much fun dropping bombs on Third World nations. Besides, those wars are all free, that's why we never paid for them.
The states are drowning in indigent care costs, and they are probably all going to realize that they could get 100% or later 90% of that money from the Federal Government if they opt in. If they don't opt in then they have to foot the indigent care just like they do now.
It would take some pretty hard-headed political thinking not to go for it. I expect that all fifty actually will, because this is real money.
Third way
Where is the the federal government going to get the money to give to the States to pay for this. The federal government can't operate with out borrowing money now. You are aware that the national debt has almost reached $16 trillion and this country is in a debt crisis?
How long do you think China is going to keep funding Obama's out of control spending?
Do you need more proof that EVERYONE in all three branches are complete idiots?