After six hours of argument challenging the 2010 health care law, the longest the Supreme Court has heard in 45 years, all sides now anxiously await the Court’s ruling.  The outcome will have profound implications for health care policy in the United States, and especially for the millions of low-income uninsured who would receive coverage beginning in 2014 under the Affordable Care Act’s (ACA) expansion of Medicaid.  The Congressional Budget Office (CBO) estimates that the law would cover 17 million through Medicaid, plus another 16 million through subsidies for private insurance.  Currently 49.9 million, about one-sixth of the population, are uninsured.  CBO estimates that absent the ACA, the number of uninsured would rise to 60 million by 2020.   None of the alternatives to the ACA offered by opponents of the law would result in significantly reducing the number people without health insurance.
The Medicaid program is a critical source of health care coverage for low-income children, some of their parents, seniors, and people with disabilities.  An estimated one in five Americans enrolled in the Medicaid program in 2011.  Medicaid, along with the Children’s Health Insurance Program (CHIP) which provides health care to children in families with slightly higher incomes, covered 31 million low-income children, 11 million non-elderly low-income parents and pregnant women, 8.8 million non-elderly individuals with disabilities, 4.6 million low-income seniors and 3.7 million seniors with disabilities.  But people who do not fit the above categories have not qualified for Medicaid, no matter how poor they are.  The Affordable Care Act will change that, allowing all whose incomes are low enough to receive health care through Medicaid.

Under the ACA, the federal government would pay 100 percent of the cost of expanding Medicaid for the first three years and 90 percent or more of the cost thereafter.  The states who are plaintiffs in the Supreme Court case are calling the Medicaid expansion coercive.  That was met with some skepticism during oral arguments.  Justice Kagan asked what was coercive about states receiving a “boatload” of federal dollars to implement the expansion.  There is plenty of precedent for Medicaid expansions that have required states to share the costs.  States always have the option to drop out of the program; they have not because Medicaid provides vital services with the federal government paying a generous share of the cost.  If the Medicaid expansion in the ACA is declared unconstitutional it would have alarming implications for all of Medicaid, not just the new provisions, and could throw into question other programs in which states are required to pony up funds as a condition of receiving federal funds.  For more information on Medicaid’s role under health care reform see this Kaiser Family Foundation issue brief .

The Court is expected to make its ruling on the constitutionality of the provisions in the Affordable Care Act in late June when the session ends.

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