Supreme Court

Does Obamacare's Medicaid Expansion Plan Violate the Constitution as Badly as Medicaid Fails its Patients?

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While much of the discussion and analysis of the oral arguments at the Supreme Court over Obamacare have centered on whether the individual mandate to purchase health insurance is constitutional, the law's Medicaid expansion raises serious legal questions as well. The Affordable Care Act includes provisions that opens up the nation's health care program for the poor to many more people starting in 2014— about 16 million more.

While the feds fund the majority of the program, states are responsible for a good share, too and Medicaid spending is the single-largest item in most (if not all) states. While states are technically free to opt out of Medicaid, it's virtually impossible to do so under Obamacare. Any state that withdraws from the program to avoid the expansion would also lose all of the feds' contribution to Medicaid. One of the challenges to Obamacare is that such a rule violates the states' rights to govern thenselves and to access their residents' tax dollars. The major precedent here is a 1987 ruling that allowed the federal government to withhold 5 percent of federal transporation dollars from states that didn't "volutarily" raise the drinking age from 18 years of age to 21 years (thanks, Ronald Reagan!). The court said that 5 percent was a small enough figure not to be an issue, but it did raise some questions about the feds' supremacy over the states that are back in play now. 

Here's Forbes' Avik Roy's summary of the issues at stake:

Most importantly from the standpoint of the Obamacare litigation, the Supreme Court [in 1987] said that these spending conditions could not be "coercive," noting that "in some circumstances the financial inducement offered by Congress might be so coercive as to pass the point at which 'pressure turns into compulsion.'"…

Roy points out that lower courts have so far said the Medicaid provisions are OK, but not without voicing big-time reservations. For instance:

The Eleventh [Circuit Court] determined, "not without serious thought and some hesitation," that Obamacare's Medicaid expansions weren't coercive. They gave four reasons: (1) Medicaid-participating states were "warned from the beginning…that Congress reserved the right to make changes to the program"; (2) "the federal government will bear nearly all of the costs associated with the expansion," capping at 10 percent in 2020; (3) "the states have plenty of notice—nearly four years from the date the bill was signed into law—to decide whether they will continue to participate in Medicaid by adopting the expansions or not"; and (4) it's not a "foregone conclusion" that states will lose their Medicaid funding if they don't comply with the law. "Indeed, the Medicaid Act provides HHS with the discretion to withhold all or merely a portion of funding from a noncompliant state."

Roy thinks this Supreme Court is too timid to make a big statement over this but…

If the High Court decides that Obamacare's Medicaid expansion is coercive to the states, this would be a huge victory for the supporters of a federalist system, and would do much to recast the balance of power between Washington and the states.

However, this group of Supreme Court justices doesn't seem especially taken to bold action. The most likely scenario is that they uphold Obamacare's Medicaid expansion, for the same reasons that the Eleventh Circuit did, but use the opportunity to articulate a multi-factor test for prohibiting Congressional coercion in the future. Either way, the Supreme Court's decision on this aspect of the case will be as momentous as its decision on the individual mandate.

More here.

By the way, in case you're wondering whether Medicaid is a good thing in reality, think on this:

Numerous studies show that, on an array of specific maladies, Medicaid's health outcomes are dismal—and in some cases worse or no better than the outcomes for individuals who lack health insurance entirely. A University of Pennsylvania study, for example, reported that colon cancer patients in Medicaid have a 2.8 percent mortality rate, compared with 2.2 percent for the uninsured. A study of Florida's Medicaid patients found they were more likely to have late-stages of prostate cancer, breast cancer, and melanoma at diagnosis than the uninsured.

More in that jugular vein here, courtesy of Reason Senior Editor Peter Suderman.

Medicaid is not a good program despite (because of?) its huge and always-growing expense. If we really want to help the poor get better medical care, scrapping this program, as inefficient and fraud-ridden as it is, would be a good first step.

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  1. no
    and now for sum miles davis
    http://www.jazzradio.com/

    1. Re: O3,

      Does Obamacare’s Medicaid Expansion Plan Violate the Constitution as Badly as it Fails its Patients?

      O3: no

      … because Medicaid already violates the Constitution totally, so it cannot get any worse than that.

      Well said, O3!

      1. Is old domesticated poodle striking at the progress of city-Statism (civilization?)

        Shall we just let city-zens die younger, more naturally, like in the good ol’ days?

        Well, shucks, city-Statism is Constitutional anyhow:

        The Constitutionality of the ACA’s Medicaid-Expansion Mandate
        by I. Glenn Cohen, J.D., and James F. Blumstein, L.L.B.
        New England Journal of Medicine; 366:103-104 January 12, 2012
        http://www.nejm.org/doi/full/10.1056/NEJMp1113416

        1. of White Imbeciles in the wild an evolutionary advantage, or just a reaction to stimuli?

          “The many studies done in the wild that observed the natural behavior of White Imbeciles have indicated no obvious or clear survival advantage of the shit-flinging behavior of White Imbeciles. It is clear we’re seeing an involuntary reflex action originated by stimuli; of what sort, we have yet to find out,” says behavioral biologist Dr. Mila Chupa of the University of Biteme.

          “There is not as yet evidence that the behavior rose as a survival skill through an evolutionary process, more likely just a mere reaction to stimuli as it is well known White Imbeciles are animals.”

          “The different patterns of behaviors of Whit Imbeciles in the Wild” by Dr. Mila Chupa, University of Biteme press, 1985.

      2. what – u dont like miles davis old mex?

  2. Reagan raised the drinking age from 18 to 21. Luckliy just after I turned 21.

    1. By edict? How did that work?

        1. I DGAF what the article says, I want to know how a president can do that without the Congress doing something too.

          1. Reagan threatened to withhold transporation funding to any states that wouldn’t raise the drinking age to 21, which would have severely screwed them over. Most states complied, with I think Hawaii, and Lousiana being the last holdouts.

  3. Numerous studies show that, on an array of specific maladies, Medicaid’s health outcomes are dismal?and in some cases worse or no better than the outcomes for individuals who lack health insurance entirely. A University of Pennsylvania study, for example, reported that colon cancer patients in Medicaid have a 2.8 percent mortality rate, compared with 2.2 percent for the uninsured. A study of Florida’s Medicaid patients found they were more likely to have late-stages of prostate cancer, breast cancer, and melanoma at diagnosis than the uninsured.

    To state the seemingly obvious: a self-selecting group of people in a risk pool for health coverage could have worse outcomes than another group, not because of the poor treatment rendered, but because the risk pool allows the very sickest individuals to choose to join it.

    1. The actual evidence on health status among enrollees and non-enrollees pretty clearly dispels that concern. Medicaid enrollees are not, as a class, sicker than non-enrollees.

  4. Under Obamacare I’d still be alive.

    1. what?
      need better sights!

  5. Britain Deserves Better

  6. Which is more likely: SCOTUS draws the line on federal funding mandates, or SCOTUS draws the line on the Commerce Clause?

    I actually think they might find it easier to do on the funding mandates. The lack of a severability clause opens the door for them to punt entirely on the Commerce Clause, and I think they might prefer to punt on the Commerce Clause rather than the federalism issue.

  7. A University of Pennsylvania study, for example, reported that colon cancer patients in Medicaid have a 2.8 percent mortality rate, compared with 2.2 percent for the uninsured.

    That may be because those with the worsening conditions felt Medicaid was some sort of magic bullet and waited almost to the point of no recovery to apply for it – another reason why I hate these University-of-wherever studies on whatever.

    1. The number could be valid if its risk-adjusted, but I don’t know if they did that.

      Risk adjustment for cancer can be done fairly well, since cancer is routinely categorized by severity.

  8. Remember folks: Fundraising for Elizabeth Warren ends on March 31st!

    So on that date, lock yourselves in your closet at home and hide your credit cards, on the slim chance you go ape and decide to do a nutty happening with your money.

  9. “Humor in a Jugular Vein.”

  10. [Corporate personhood] is not a good program despite (because of?) its huge and always-growing expense. If we really want to help the poor get better medical care, scrapping this program, as inefficient and fraud-ridden as it is, would be a good first step.

    FIFY. And remember this:

    Even the brother of Koch Industries owners David and Charles Koch called the company an “organized crime” operation.

    I’m sure the whole industrial medical complex is as fraud ridden as teh Koch.

    Gummit and gummit programs are the kind of profitable fraud that the capitalist elite purchase when they fly their jets into Washington National and limo down to K Street.

    Money talks, bullshit walks.

    1. The nitwit who believes science = empiricism and confuses markets with money now pretends to lecture people on what is Capitalism.

    2. of White Imbeciles in the wild an evolutionary advantage, or just a reaction to stimuli?

      “The many studies done in the wild that observed the natural behavior of White Imbeciles have indicated no obvious or clear survival advantage of the shit-flinging behavior of White Imbeciles. It is clear we’re seeing an involuntary reflex action originated by stimuli; of what sort, we have yet to find out,” says behavioral biologist Dr. Mila Chupa of the University of Biteme.

      “There is not as yet evidence that the behavior rose as a survival skill through an evolutionary process, more likely just a mere reaction to stimuli as it is well known White Imbeciles are animals.”

      “The different patterns of behaviors of Whit Imbeciles in the Wild” by Dr. Mila Chupa, University of Biteme press, 1985.

  11. Scrap Medicaid? Why do you hate the poor?

  12. volutarily

    Uh….

  13. I just asked this in the morning links thread, but why is it that the justices will be voting and writing opinions Friday, but we won’t get a ruling until June?

    1. The way this works, I understand, is that there’s quite a bit of drafting a negotiation on who joins what opinion, etc.

      They don’t want to announce until they can publish opinions, and that can’t happen until all the tweaking is done.

      And, in this case, they want to make sure they have their flights booked to get the hell out of town, if not the country, when the decision is announced.

  14. Votes don’t buy themselves.

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