The ACA and Responsibilities of the States

By: Sharita Thomas  

There are many quotes about procrastination and general stubbornness that can be used to scold the states that willingly refused or were hesitant to plan for the future provisions of President Obama’s Patient Protection and Affordable Care Act (ACA). Abraham Lincoln is noted for having said that, “you cannot escape the responsibility of tomorrow by evading it today.” Currently, there is much work to be done among states’ leadership that evading the responsibility to start on an appropriate plan in accordance with the health reform law, already over two years old.

The ACA, affectionately known as “Obamacare,” was signed into law in early 2010 with major provisions scheduled to take effect by January 2014.  The overall goals of the ACA are to address what most agree to be fundamental problems with the U.S. health care system: large numbers of uninsured, rising health care costs, underinsurance, questionable quality, and fragmentation.  One rapidly approaching provision is the expansion of state Medicaid programs to 133% of the federal poverty level to increase the number of insured individuals. Medicaid is the largest public health insurance program in the U.S., being financed by state and federal funds but administered at the state level to cover the low-income population. Historically, Medicaid is as an area of contention among legislators attempting to balance state budgets.

The ACA is by no means a flawless measure and faced large pushback, including legal suits. In June of this year, the Supreme Court ruled on several arguments birthed by the ACA. One of these rulings revised a key tenant of the ACA, making it optional for states to expand their Medicaid programs. Hesitant states- West Virginia, New York, and North Carolina- have been slow to plan, trying to weigh the best option for their populations, while republican-led states- Florida, South Carolina, Texas, Mississippi, Louisiana, and Georgia- adamantly resisted expansion efforts. Much of the reluctance was speculatively linked to the uncertainty of the outcome of the 2012 presidential election. Were republican presidential candidate Mitt Romney to have come out as the victor last Tuesday evening, there is little doubt that the ACA would be left dysfunctional by pernicious funding measures.

Now that the smoke has cleared and President Barack Obama has secured re-election and extended the life of his landmark health reform law, states that were hopeful of a different outcome and those that were uncertain can no longer delay action. There is little justification, political or otherwise, that can be postured toward constituents. However, significant time has passed making any substantial progress on a functional plan doubtful for some of these states by the time the insurance exchanges begin operation in 2014. The insurance exchanges, another key provision of the ACA, allow for low and middle income people to purchase private health insurance through federal subsidies (reaching below 400% of the FPL). But states that choose not to expand their Medicaid programs to meet the level of subsidy requirement in the exchanges have the potential to leave people that fall out in an income range between Medicaid and subsidy eligibility without an affordable means to access health insurance.

Having procrastinated work on a plan and not publicizing potential pathways for incorporating provisions of the ACA may leave residents of certain states to demand of state officials how they intend to manage. States that have remained active in working towards being prepared for the 2014 provisions, like California, are able to assure progression on their plans to their population. Since November 2010, California has been developing health reform plans to expand coverage to more than half of its 7 million uninsured. The presidential election results and passage of the state’s Proposition 30 allow California to continue its progressive momentum toward stabilizing health care costs. North Carolina, largely undecided in the issue and facing a new republican governor in January, can do little presently to answer questions concerning the fate of its some 1.5 million uninsured. Newly elected North Carolina governor Pat McCory will inherit the responsibility of leading the state’s lawmakers in a direction on health reform without the guidance of previous plan or outline from the General Assembly or Governor Purdue. Florida, vocal in its stance on refusal to expand Medicaid, now has to answer a call to voters who welcome “universal coverage” after rejecting Amendment 1 on November 6th.

The ACA is a complicated and imperfect measure. Medicaid expansion is not easy for any state Medicaid director to deal with as budgets are always tight and current program issues-like increasing enrollments as a result of the recession,  demand attention. Additionally, the continuation of the ACA means that states will need to eventually increase Medicaid expenditures. The ACA is quite demanding of states and their responsibility to their population. But state leadership that continues to drag their feet on the issue due to the difficulties associated with implementation or their disagreement on the principles of the law are only setting their working class population up for even harder times. For the demands of the ACA on states, it was quite clear that strategies needed to be developed sooner rather than later for states to have clarity on the best needs of their population. Hopefully, the states that are far behind will be able to catch up, avoiding penalties on their population as a result of leadership’s procrastination.

Rage Against The (Chinese) Machine

Move Over, Grover