In 2008, the United States had an election, and the American people overwhelmingly elected a president and a Congress who believes it is a moral abomination that, in the wealthiest, most powerful nation that ever existed, tens of thousands of Americans die every day because they cannot afford lifesaving treatment. Today’s decision upholding nearly all of the Affordable Care Act reaffirms that the American people’s decision matters. In Chief Justice Roberts’ words,
Members of this Court are vested with the authority to interpret the law; we possess neither the expertise nor the prerogative to make policy judgments. Those decisions are entrusted to our Nation’s elected leaders, who can be thrown out of office if the people disagree with them. It is not our job to protect the people from the consequences of their political choices.
Yet, while today’s decision is fundamentally a reminder that the United States is a democracy, it also complicates matters quite a bit. For reasons that will be explained in a subsequent post, the opinion butchers an understanding of two key constitutional provisions that prevailed in the very earliest days of the Republic. Perhaps most significantly, it also creates an unprecedented new limit on the federal government’s ability to partner with the states in order to solve national problem — and this limit could cost millions of low-income Americans their access to health care.
Under Medicaid, the feds offer funding to the states to enable them to provide health services to the poor. The states are free to take this money or to leave it on the table, but if they accept it they are required to comply with certain conditions. Nevertheless, the plaintiff challenged Obamacare’s expansion of Medicaid to provide health care for all people earning up to 133 percent of the poverty line, claiming that the law somehow “coerces” states into taking this new money. Roberts’ opinion buys this argument, holding that, because the states must accept Obamacare’s new Medicaid funds in order to continue receiving old Medicaid funds, that constitutes unconstitutional coercion.
One piece of good news is that Roberts distinguished the Affordable Care Act’s Medicaid expansion from previous expansions enough that his opinion probably would not lead to those past expansions being retroactively struck down. Another is that the opinion does not invalidate the Affordable Care Act’s Medicaid expansion either. Instead, it says that conservative states are now free to take the new Medicaid funds or leave them without risking any of their old funds.
The upshot of this is that Rick Perry’s Texas can now decide that it would rather give the finger to Obamacare than provide health care to hundreds of thousands of its residents, even though the federal government will cover 90 percent or more of those costs. Doing so, of course, would be cruel; it would save Texas very little money; and it would probably be unpopular with many Texas voters. But Texas now has this option if it chooses.
In the long run, it is likely that Texas will eventually fall in line — just as every single state in the country eventually realized that the existing Medicaid program is a really good deal that they should agree to. While political fires are burning hot, however, many low income Texans (and Mississippians, and Oklahomans . . . ) are likely to suffer for it.