Friday, June 29, 2012


The Court's cramped view of Medicaid expansion means that low income people will bear the individual mandate 'tax' disproportionately. Upholding the requirement that individuals buy private insurance while allowing states to opt out of Medicaid expansion is the worst possible outcome. Achieving universal coverage by compelling low income Americans to purchase private insurance will protect health industry profits at the expense of people most in need of health care for all.

The precise consequence of the Court's ruling on Medicaid expansion is not yet knowable, as states have the right to accept the federal terms of expansion.  States that do accept Medicaid expansion will cover people whose incomes fall below 133% of the poverty line, including people who are categorically excluded under most state Medicaid programs today -- individual adults between age 19 and 65.

But as 26 states challenged the Medicaid expansion provision of the Affordable Care Act,  it is reasonable to anticipate that some states will opt out the Medicaid expansion program now that they have the right to do so.  HALF of the 32 million people the Affordable Care Act promised would achieve health care coverage were slated to secure their coverage through expanded Medicaid. A sizeable subset of the 16 million who would have been covered under expanded Medicaid may be opted out by their states, depending on where they live.  This pulls the legs off the structure of "universal coverage" under the Affordable Care Act, leaving economically vulnerable people, disproportionately of color, out in the cold world of medical impoverishment.

In the worst case, 16 million low wage workers who do not have health insurance where they work will be forced into the health care exchanges where they must obey the individual mandate to buy insurance.  A system of hardship exemptions and graduated, income-based subsidies and rebates will attenuate some of the economic burden that befalls low income American -- assuming the subsidies are fully funded and that the current funding formula stands.  But this won't mitigate the fact that the currently uninsured -- overwhelmingly because they cannot afford insurance -- will be the most vulnerable, unequal participants in the new system.

For a critical consideration of the inequality effects of the Supreme Court's Obamacare decision, see:

For a discussion of the attitudes of states toward Medicaid expansion, see:

For a general review of the Obamacare decision, see:

For an example of how the health insurance subsidies will be calculated, see:

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