The Affordable Care Act and States’ wrong

The Supreme Court issued a lot of important and sensible rulings last week: enshrining marriage equality as the law of the land, supporting the Fair Housing Law claims of disparate impact, and ruling that the Affordable Care Act subsidies are legal in every state. More work awaits those fighting for human rights for all, an end to housing discrimination, and health care for everyone.

Opponents of these decisions like to talk about state’s rights, an issue that has a long and sometimes tortured history, ranging from discussions of constitutional powers under the 10^th Amendment to its use as coded language for supporting racial discrimination and outright racism.

What we don’t talk about enough are states’ wrongs. And, with regard to the Affordable Care Act, it is vital to talk about states in the wrong. The law as originally intended required states to expand Medicaid. The Supreme Court, as part of its 2012 decision upholding the law's constitutionality, made expansion an option for states. Funding was unchanged: the federal government pays 100 percent of the costs from 2014 to 2016 and then phases down to 90 percent by 2020. Coverage is provided to adults under age 65 with income up to 138% of the federal poverty level  and children up to age 18 up to that income level or higher. Thirty states, including Pennsylvania, New Jersey, and Delaware, said yes, as did the District of Columbia.

Twenty-two states said no to Medicaid expansion–and with that choice left 4.3 million Americans uninsured. Those states simply chose not to provide health coverage to low-income individuals. That is a states’ wrong, and the health impact of this wrong is to be far reaching. One study estimated that thousands of people would die every year as the result of states' failure to expand Medicaid.

Most but not all of the states refusing to offer expanded coverage are in the south and are places where the slogan “state’s rights” has long been used to justify discrimination. In some of these states, in the wake of the racially motivated and horrific act of domestic terrorism and mass murder at the Emanuel African Methodist Church in Charleston, S.C., elected officials have brought down the confederate flags flying on state property. Good move (although let’s be clear, the Confederacy was defeated 150 years ago so it’s a bit late). Yet some of the same elected officials who want to remove what South Carolina Gov. Nikki Haley calls “a symbol that divides us” are still happy to maintain a divide between those who can access health insurance and those who cannot.