Perspective:

The biggest of the many surprises found in the Supreme Court’s June 28 decision on the Affordable Care Act (ACA) may have been the Court’s conclusion that the law’s Medicaid expansion scheduled for 2014 was unconstitutional. Recent data suggest that Medicaid expansion in New York, Maine, and Arizona was associated not only with improved health care coverage, but also with reduced mortality. However, given the clear language of the Court’s decision, the verdict permits states to decide whether to accept funding to support the Medicaid expansion for newly eligible adults as a group or to reject it and with it hundreds of billions of dollars in much-needed federal assistance. But some states may press the administration to interpret the expansion as a simple state option, allowing them to cover some portion of the expansion group and not others. This approach has no support in the law and would invite states to leave the most vulnerable members of the expansion group, namely adults without children exposed to the worst sort of discriminatory exclusion. The administration may then be pressured to enter into negotiations with each state, using its waiver authority. We hope that the states will come to their senses and spare us the political bickering of federal and state governments struggling over the lives and health of the poorest among us.