Three weeks after the U.S. Supreme Court upheld most of the Affordable Care Act by interpreting the penalty for refusing to buy health insurance as a tax rather than commercial coercion, the followup skirmishes are just beginning.
The main event must wait until after November’s election. If President Obama gets re-elected, he’s certain to veto any legislation that would kill the law. If Mitt Romney wins, he’s promised his first day in office will be the beginning of the end for “Obamacare.” If Republicans win the Senate as well as the White House, they’ll be on track to pursue their effort to “repeal and replace” the health care law. If they don’t win, the game’s probably over.
Meanwhile, the states have some decisions of their own to mull over. Kentucky Gov. Steve Beshear made one Tuesday when he started work on a statewide insurance exchange – consistent with his prior commitment. The online guide to insurance options and advice will assist those who’ll have to buy health insurance under the law’s “individual mandate.”
This step immediately encountered political resistance, indicating conservative opponents of government-administered health care won’t surrender quietly, whatever the Supreme Court said. After Beshear kept his promise to establish an exchange once the legislation was upheld, his plan to house the new service in leased Frankfort office space went to the Capital Projects and Bond Oversight Committee, which voted 4-3 against the proposal. Republicans prevailed but Beshear said he’d exercise his prerogative to proceed.
A decision is yet to come on the part of the court ruling which held states have a right to “opt out” of the law’s proposed expansion of Medicaid – the program that funds medical treatment for the poor. States going along with Obama’s plan would cover not only deeply impoverished patients but also those who make less than 133 percent of poverty-line income. Progressives are pushing hard for governors to get with the program but some, especially those of the Republican persuasion, are reluctant.
Beshear, who picks and chooses conservative or liberal positions depending on the context, has not announced where he stands on the issue. This poor state already has a significant portion of its population on government assistance, belying Kentuckians’ professed distaste for big government. Few turn up their noses at Social Security or Medicare, but some may draw the line at a bigger Medicaid bureaucracy.
In the near term, states might be tempted to sign on with the expansion, given that the federal government promises to cover the added cost in the early years. Afterwards, financially strained states will have to take on more of the burden themselves.
Even unexpanded Medicaid has been a fiscal stretch over the past year. A special legislative session was called to balance the 2011 budget because the federal government sent Kentucky less Medicaid funding than expected. Lawmakers dealt with the crunch by borrowing from a future budget and accepting the governor’s plan to rely on managed care to reduce costs. Committing to even more state spending on Medicaid in years to come would represent a major act of faith in the progress of the economic recovery.
There’s obviously more at issue than “repeal and replace.”