New America Media, Commentary, Toni Miles, Posted: Jun 29, 2012

ATLANTA, Ga.—This week’s U.S. Supreme Court decision provides clarity. America won today. Do not be fooled by political spin. States needed to know that current federal dollars for Medicaid would not be endangered by the program’s expansion to provide health care coverage to 17 million uninsured Americans.

States--like many households--are faced with making terrible spending choices. All governors are weighing the choice between spending on health care and other state priorities. With its decision to uphold the expansion, the court clearly stated that states are free to choose the balance that works for them.

Within health care spending, long-term care and health care for families facing chronic illness, disability or frailty in old age are significant competing needs. If seniors are our past and children our future, states must be free to honor one and protect the other.

Immigrant and Minority Women

Think about all the lower-income immigrant and minority women, who provide support their family members at both ends of the age spectrum. Without Medicaid support, these adults would have to withdraw from the workforce. Working adults in low-wage jobs won in the Supreme Court this week.

Medicaid is the public health insurance that supports both seniors and dependent children. The expansion refers to the provision in the Affordable Care Act (ACA) to broaden the definition of qualified Medicaid participants.

By redrawing the income line, the ACA Medicaid expansion creates coverage for working adults, who fall at or below 133 percent of the federal poverty line. States accepting the new program cannot set the eligibility line lower, as many do now with the existing Medicaid program. And they cannot reserve eligibility only for people who fit certain categories, such as low-income women with children or people with certain levels of disability. Income is the only measure.

The court’s decision endorses a state’s right to make choices consistent with local needs and limits. That is, states can choose to participate in the expansion—or not. And states—and their leaders--will manage the consequences of their choices.

The expansion also differs significantly from the existing Medicaid program in how it is funded. The current program is jointly financed by the states and federal government, with each state managing the program under minimum federal rules. The federal government pays form 50-70 percent of the Medicaid bill, covering the greater amount for states with higher levels of poverty.

The new expansion is a period when the federal government pays the premiums of newly eligible enrollees. For the first three years after the provision goes into effect in 2014, the federal government will pay the entire premium of new Medicaid enrollees. During the next five years of the expansion, the federal government will pay 90 percent of the premiums.

What happens after that? We do not know. This economic uncertainty is giving all the governors heartburn. History teaches us that the economy will get better. It might just take a while.

The Supreme Court decided to uphold the expansion, but it nullified ACA’s original stipulation that if states refuse to accept the program the federal government could withhold all of its Medicaid funding. The court said states can chose to reject the expansion, but cannot lose existing funds. Few believe that many states, if any, will ultimately refuse the generous federal funding to protect so many of their citizens.

A Health Care Vision at Both Ends of Life

Medicaid is the only insurance plan in the United States that provides support for both ends of life. In the United States, almost 60 percent of all children are born with the support of Medicaid. The health of pregnant women and their newborns is tied to Medicaid.

Also, in the U.S., Medicaid is the primary source for financing long-term care for seniors. Before the enactment of Medicaid in 1965, seniors needing long-term care had no options if they had no family.

Medicaid protects children. Medicaid honors the contribution of our older adults. The program’s expansion supports both of these commitments. It is not a permanent fix, though. The expansion buys the states time to address the need for long-term care financing.

In my vision of the road ahead during the ACA expansion period, all states will begin designing a response to the growing need for long-term care. There will always be a need for institutional care.
However, many people can be better served in their homes. Most of us want care in our homes.

Aging boomers, in particular, want care in their homes. All boomers (like me) need to consider financing care their own care. In my vision, by the end of the Medicaid expansion, the economy is better. Fewer people need Medicaid’s assistance. Adults begin to take responsibility for their need for long-term care in old age—with the help of an affordable and reliable long-term care insurance market not currently available.

I know it is a fantasy but it can become reality if we begin today. This week, the court gave back our freedom to choose. Let us seize the day.

Toni Miles , M.D. Ph.D., directs the Institute of Gerontology at the University of Georgia College of Public Health. Her new book, Health Reform and Disparities : History, Hype, Hope, (Praeger, 2012) analyses the impact of the Affordable Care Act. In 2008-2009 she was a John Heinz Foundation/Health and Aging Policy Fellow working on health care reform legislation with the U.S. Senate Finance Committee in Washington, D.C.