What Missouri’s surprise expansion of Medicaid shows about the big debates to come

What Missouri’s surprise expansion of Medicaid shows about the big debates to come

This is not just a story about one conservative state. It contains an important lesson for Democrats, one they should not forget if they win control of the federal government in November. Although it got less attention than other provisions when the ACA passed in 2010, the expansion of Medicaid may have been the most significant thing the law did, providing health coverage to millions of Americans. Under the status quo, each state set eligibility for the joint federal-state program, which in practice meant that liberal states provided insurance to most poor people and Republican states restricted the program to as few people as possible. For instance, Texas sets eligibility for adults at 15 percent of the federal poverty level, so if you’re in a family of four and you earn more than a princely $3,930 a year, you’re too rich to get Medicaid. Which is a big reason that even before the pandemic, about 5 million Texans lacked health coverage. So under the ACA, Medicaid would be expanded to the same level everywhere, with anyone making less than 133 percent of the poverty level ($34,846 for a family of four) eligible for coverage. But in 2012 — in a decision born more of horse-trading among justices than constitutional analysis — the Supreme Court ruled that states could opt out of the expansion if they wished. And in Republican-run states, they did indeed wish. It didn’t matter that the federal government would pick up 90 percent of the cost, or that study ...
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