Harold Pollack Helen Ross Professor of Social Service Administration, University of Chicago Adjunct Fellow, Century Foundation

 ACA, including its Medicaid expansion, arguably most important public health measure in five decades.  More important HIV policy than the National AIDS policy.  More important substance abuse policy than the National Drug Strategy  Both big provisions and fine print extremely important  Many stakeholders have reasons to regret imperfections and compromises in ACA. Less so in public health.

(Kaiser Family Foundation)

 Consider predicament of “typical” substance abuser, homeless person, extremely poor person in much of U.S. circa July 11,  Who will pay for his substance use treatment, or the treatment of physical health comorbidities?  Right now, he’s Medicaid ineligible in most states.  He’s not a mom.  He’s not a veteran.  He has no health condition that qualifies as a federally- recognized disability for purposes of SSI or SSDI.  He does not have AIDS (though he might have contracted HIV).  His services financed through a patchwork of safety-net programs and (often) uncompensated care.

 In 2014, he will become Medicaid-eligible simply because his income is below 138% of the poverty line.  Important to finance substance abuse treatment and other services to that individual.  Such expanded eligibility also important to the institutions and payers that assist that individual or provide safety-net care.  Critical issue for city and county governments, that often bear burdens caring for uninsured.  ACA also includes critical language expanding coverage of SA/MA issues—and at parity.

 National Federation of Independent Business v. Sebelius constrained federal power in new way, and opened new choices for states.  States may now decline to participate in Affordable Care Act’s Medicaid expansion.  The full implications of this decision have yet to be felt—both within Medicaid and in the broader contours of state-federal relations.

(Advisory Board)

 “Put up or shut up” moment for many governors and state legislators.  ACA offers states (over time) roughly 19:1 federal matching funds to finance services often provided through public sector.  $50 billion in the case of Texas, requiring $2.4b from state.  Many constituencies have strong stake in Medicaid expansion.  First VA then Medicare history encouraging in desegregating southern hospitals.  Early Medicaid history also encouraging.  The real financial hit to some states is not ACA expansion, but high takeup among those already eligible.

(Kaiser Family Foundation)

Top states: Mississippi, Arkansas Oklahoma, Kentucky, SC, Oregon, NM, Alabama, Montana, WVa, NC

(Courtesy Austin Frakt)

 Substantial implementation challenges  Supreme Court decision shifts bargaining power between states and the federal government.  Misplaced panic over Medicaid quality, cost, fiscal burdens, and anticipated growth

 Cutting Medicaid costs requires either painful cuts to elderly, blind, and disabled, OR cutting off coverage for tens of millions of low-income working age people.

 Medicaid proposals shifting costs and risks onto individuals and onto states  Bloc granting Medicaid, with bloc grants rising slower than costs of care.  “Repeal and reverse” a serious challenge to structure of program.  Raising federal share of existing Medicaid burden a better response to concerns/failures at state level.  But that would be a different talk.