1. MISSING PIECES IN THE ACA PUZZLE Joel Weintraub, M. D. , J. D
MISSING PIECES IN THE ACA PUZZLE Joel Weintraub, M.D., J.D. October 16, Disclosure: I have no financial conflicts of interest relevant to this presentation.

2. MISSING PIECES: MEDICAID
How has the Supreme Court’s decision in National Federation of Independent Business v. Sebelius affected the ability of the ACA’s expansion of Medicaid to reduce the number of those without health insurance?

3. National Federation of Independent Business v. Sebelius
The Spending Clause grants Congress the power "to pay the Debts and provide for the ... general Welfare of the United States." U.S. Const., Art. I, § 8, cl. 1. We have long recognized that Congress may use this power to grant federal funds to the States, and may condition such a grant upon the States’ "taking certain actions that Congress could not require them to take."

4. National Federation of Independent Business v. Sebelius
At the same time, our cases have recognized limits on Congress's power under the Spending Clause to secure state compliance with federal objectives.
Respecting this limitation is critical to ensuring that Spending Clause legislation does not undermine the status of the States as independent sovereigns in our federal system.

5. National Federation of Independent Business v. Sebelius
The threatened loss of over 10 percent of a State's overall budget, in contrast, is economic dragooning that leaves the States with no real option but to acquiesce in the Medicaid expansion.

6. National Federation of Independent Business v. Sebelius
As for the Medicaid expansion, that portion of the Affordable Care Act violates the Constitution by threatening existing Medicaid funding. Congress has no authority to order the States to regulate according to its instructions. Congress may offer the States grants and require the States to comply with accompanying conditions, but the States must have a genuine choice whether to accept the offer.

7. National Federation of Independent Business v. Sebelius
The decision gave each state the ability to accept or reject the expansion of Medicaid without loosing funding for existing Medicaid programs.
Upheld all other provisions of the ACA including the individual mandate. Penalties for failure to obtain insurance were upheld under the Taxation Clause.

8. STATES’ ACTION As of September 30, 2013,
24 states and the District of Columbia have accepted the expansion of Medicaid.
New York, New Jersey and Connecticut have accepted.
Includes Arizona and Iowa

9. STATES’ ACTION As of September 30, 2013,
26 states have not accepted the expansion of Medicaid.
4 of the 26 (North Carolina, Texas, Utah and Wyoming ) have passed legislation prohibiting the expansion of Medicaid.
Includes Pennsylvania

10. STATES’ ACTION There is no deadline for acceptance.
Many more states many eventually accept the expansion

11. STATES’ ACTION
Even in states not accepting the expansion, Medicaid enrollment and expenditures will likely increase.
ACA requires simplification of application process even for traditional Medicaid.
No “wrong door”
Elimination of in-person interviews
Eligibility discovered by Exchanges.

12. STATES’ ACTION
Those with income below 100% of Federal Poverty Guidelines will not even qualify for subsidies for purchase of insurance.
States’ Disproportionate Share Hospital Payments will decrease even if expansion of Medicaid not accepted.

13. STATES’ ACTION Projections for 2014:
For states accepting expansion, Medicaid enrollment will increase 12%, and spending by the state will increase 4.4%
For states not accepting expansion, Medicaid enrollment will increase 5%, and spending by the state will increase 6.1%

14. STATES’ ACTION
Federal government would pay 100% of cost of expansion. (No less than 90% after 2016)
The expansion would cover all adults with income less than 138% (133% plus 5% income exclusion) of Federal Poverty Guideline.
Without expansion the median eligibility limits in non-accepting states is estimated to be 0% for childless adults and 47% for parents.

15. THE UNINSURED In 2007, 43.4 million In 2010: 49.2 million
Projections for the effect of ACA:
In 2022: 22 million if all states adopt expansion representing a reduction of 25.3 million.
In 2022: million with no expansion representing a reduction of 15.1 million

16. THE UNINSURED
A full expansion of Medicaid would have accounted for a 10.1 million reduction of the number of uninsured by 2022.

17. THE QUESTION
How has the Supreme Court’s decision in National Federation of Independent Business v. Sebelius affected the ability of the ACA’s expansion of Medicaid to reduce the number of those without health insurance?

18. ANALYSIS
If no additional states accept the expansion of Medicaid approximately 5 million fewer of the uninsured will be covered by 2022.
Parameters of comparison
Population
Magnitude of coverage change
Number of uninsured
Potentially a 20% reduction in the ability of the ACA to reduce the number of uninsured.

19. REFERENCES
Center for Disease Control, Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, 2012,
Federal Register, Jan 24, 2013, 78(16): , Poverty Guidelines
National Federation of Independent Business v. Sebelius, 132 S.Ct (2012).
Patient Protection and Affordable Care Act, Pub. Law No , 124 Stat. 119 (2010), as amended by the Health Care and Education Reconciliation Act of 2010, Pub. Law No , 124 Stat (2010) (amending §5000A of the Internal Revenue Code of 1986) [commonly, "ACA"].

20. REFERENCES
The Henry J Kaiser Family Foundation, Status of State Action on the Medicaid Expansion Decision, as of September 30,
The Henry J Kaiser Family Foundation, The Kaiser Commission on Medicaid and the Uninsured, Medicaid, A Primer,
The Henry J. Kaiser Family Foundation,
The Henry J. Kaiser Family Foundation,

21. THANK YOU

22. ADDITIONS Medicaid enrollment 2012 excluding CHIP:
Children 31 M (CHIP additional 8 M)
Elderly 8 M
Disabled 8 M
Other adults 16 M
Total 63 M

23. ADDITIONS Medicaid represents 16% of health care spending. $416 B
16% X $2.6T = $416
Medicaid could expand by 16% for a total increased cost of $1.1 T if all states accept.

24. ADDITIONS
Federal Poverty Guidelines for 2013 according to family size:
1: $11,490
2: $15,510
3: $19,530
4: $23,550
Is approximately 3 times the cost of food in 1963 adjusted by CPI.

25. ADDITIONS
Accepting by legislation: Arizona, Arkansas California, Colorado, Connecticut, Illinois, Iowa, Maryland, Massachusetts, Michigan, Minnesota, New Jersey, New Mexico, New York, North Dakota, Rhode Island, Washington.
Accepting by executive action: Delaware, District of Columbia, Hawaii, Kentucky, Nevada, Oregon, Vermont, West Virginia.
Total 25

26. ADDITIONS
Not accepting by inaction: Alabama, Alaska, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Mississippi, Missouri, Montana, Nebraska, New Hampshire, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Virginia, Wisconsin.
Not accepting by legislation: North Carolina, Texas, Utah, Wyoming.
Total 26