« October 2012 Issue

The Supreme Court Ruling on Medicaid: What's at Stake

June's highly anticipated Supreme Court ruling upholding the constitutionality of the Affordable Care Act (ACA) was welcome news, but the high court's "sleeper" decision allowing states to opt out of expanding Medicaid threatens a central tenet of the law: guaranteeing new health care security for millions of vulnerable Americans.

The stakes are particularly high in 12 Southern states where the ACA has made nearly seven million people, most of them working poor, newly eligible for coverage under Medicaid. As a region, Southern states have the highest rates of uninsurance in the nation - as high as 33 percent in Texas and 27 percent in Arkansas and Florida. They also have the most stringent Medicaid eligibility standards. With the exception of Tennessee, all of the southern states limit Medicaid eligibility for working parents to only those whose annual income is less than 100 percent of the Federal Poverty Level (FPL), or roughly $18,500 for family of three.  In Arkansas, for example, a family of three earning just slightly more than $3,245 does not qualify for Medicaid. In contrast, 18 states — including the District of Columbia — offer Medicaid to working parents at or above 100 percent FPL.

Racial and ethnic diversity also characterizes the region. Fifty-seven percent of the U.S. Black population lives in the South. Over the last ten years, the Latino population grew by more than 50 percent, while a disproportionate part of the workforce remains low wage. These characteristics have fed longstanding and deep health and health care disparities among people in the region.

By helping to level the health care access and affordability playing field, the ACA will reduce both health disparities and the gulf between economic classes for Southerners. The ACA expands coverage to adults who earn up to 133 percent of the FPL (around $25,000 for a family of three) through Medicaid.  The federal government will pay 100 percent of coverage costs for the newly eligible from 2014-2016 - and an average of 95 percent of those costs between 2014-2019.  Those who gain coverage for the first time will be able to obtain needed health and wellness services and be shielded from the burden of unpaid medical bills. Job growth and new educational opportunities also will result from billions of new federal dollars flowing through the health system.

Despite the financial bargain resulting from billions of federal dollars committed to finance state Medicaid expansions, six southern governors have announced their opposition to moving forward. Others are on the fence. Speculatively, some might be amenable to taking this step after the fall election.

 "Health advocates in Southern states are deeply concerned that the Supreme Court's decision might thwart a historic opportunity to greatly improve the overall health and economic security and well-being of people living in the South," says Dara Taylor, director of Community Catalyst's Southern Health Partners project. "But advocates in the region believe that they can build or augment coalitions with other key stakeholder groups and mount successful campaigns to persuade state policymakers to move forward. They have demonstrated the impact advocacy can have in the region — successfully preventing cutbacks in state Medicaid budgets — through campaigns raising tobacco taxes and creating other alternative funding streams for health programs."

Cindy Mann, Director of the Center for Medicaid and CHIP Services at the Centers for Medicare and Medicaid Services, in a keynote address at Community Catalyst's annual Consumer Voices for Coverage conference on September 13, encouraged advocates to launch Medicaid expansion campaigns state-by-state and coordinate their actions. Southern states moving forward will show the rest of the nation it can be done anywhere, she said. She urged advocates to use compelling "human touch" consumer stories to illustrate the dramatic impacts Medicaid coverage can have on the lives of people it serves.  

Through the Southern Health Partners project, Community Catalyst is working with consumer advocacy groups in all 12 Southern states to help them develop strategies aimed at Medicaid program expansion and to defend existing safety-net and public health programs threatened with budget cutbacks.

"We hope to propel this work forward by generating a sustained investment and by helping to facilitate groups working together throughout the region," said Taylor. Noting the absence of federal or state funds to support consumer engagement, she said, "That's a void foundations could help fill."

Despite still-limited resources, groups are moving forward. Advocates in Virginia, Louisiana and Tennessee recently released reports detailing for state policymakers the benefits of expanding Medicaid coverage with federal dollars. Throughout the region, advocates are hosting public forums, organizing sign-on letters to governors, engaging with hospitals, providers, and local employers, and developing stories to present to elected officials and the media about who in their states who will benefit.

"We have a proven advocacy model that can make a difference for people in the South with the right investments from institutions and individuals who care about social and economic justice," said Taylor. "At the end of the day this isn't just a health care issue - it's about lifting people out of poverty. Health security is key to economic security and opportunity for millions of people in the region."

O N   T H E   W I R E

Robert Restuccia, executive director, joined a Boston Globe panel to discuss next steps for moving forward on Affordable Care Act implementation after the Supreme Court ruling on the law.

David Jordan, Dental Access Project director, explained to the Minnesota Star Tribune that states across the country are looking to the dental therapist model in operation in Alaska and Minnesota to help expand access to the 82 million Americans without dental care.

Jessica Curtis, Hospital Accountability Project director, underscored the importance of strong federal regulation in protecting consumers from crippling medical debt and unfair hospital billing and collection processes in The Boston Globe and in Modern HealthCare.

The New England Alliance for Children's health released a policy brief on The Sickle Cell Treatment Act on opportunities for advocacy to fully implement the law and draw down additional Medicaid matching funds to conduct public outreach and education about the disease.

Anna Dunbar-Hester and Eva Marie Stahl, policy analysts, laid out the impact the Affordable Care Act will have on millions of Americans-highlighting key benefits for consumers and explaining how the law strengthens the safety net-in the Boston Bar Association's Health Law Reporter

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