The Millions Left Out of Health Reform by John Roberts

John Roberts struck down a key Medicaid provision that would have penalized states that didn’t expand their coverage.

Photo by Chip Somodevilla/Getty Images

This is not news to people who’ve been following the Affordable Care Act closely, but Sabrina Tavernise and Robert Gebeloff have a timely reminder in the New York Times that the implementation of Obamacare “will leave out two-thirds of the poor blacks and single mothers and more than half of the low-wage workers who do not have insurance.”

But something that’s worth noting here more prominently than they do is that this is not an oversight of the law or of the Obama administration. It’s due to the actions of Chief Justice John Roberts and then to a number of Republican Party state and local elected officials led by Texas Gov. Rick Perry. What happened is that the Affordable Care Act relies on an expansion of Medicaid to provide health insurance to many poor families. Yet Medicaid is a joint state/federal program and states have substantial leeway in deciding how many people get Medicaid coverage and on what terms. So the authors of the law decided to make state governments an offer they couldn’t refuse—on the one hand, expansion would be nearly 100 percent paid for by the federal government while on the other hand failure to expand would come with significant financial penalties.

Then came Roberts. In his landmark ruling upholding the constitutionality of the individual mandate, he burnished his conservative cred by striking down the penalties portion of the Medicaid expansion.

That’s where the problem comes from. Still, it should have been no big deal. Medicaid expansion on these terms is a no-brainer, which is why a range of Republican governors from Michigan to Arizona have embraced it. But most GOP legislators in those states still reject the idea, and Republican officeholders in the south are especially resistant. This becomes a huge problem because the very conservative states whose politicians are most hostile to the idea of poor people getting health insurance coverage are precisely the places that have the largest number of uninsured people. So the nonparticipation of Texas in the expansion just on its own takes a huge bite out of its effectiveness.

A couple of the states that don’t expand Medicaid in 2013 will, I think, change their minds fairly soon. Perhaps right after the 2014 midterms. And in a place like Texas that’s superconservative but much too large for Democrats to ignore, the expansion issue will give the party a shot in the arm and a good issue to talk about. Expansion won’t win right away, but it should win soon enough. But Mississippi? Alabama? There are going to be pockets of the country where poor people continue to lack insurance for quite a long time, all thanks to Roberts and the stubborn intransigence of conservative politicians.