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LINDA WERTHEIMER, HOST:

This is MORNING EDITION, from NPR News. I'm Linda Wertheimer.

RENEE MONTAGNE, HOST:

And I'm Renee Montagne. The Supreme Court's decision to uphold nearly all of the Affordable Care Act shifts the continuing debate over the law to the presidential campaign. And it shifts much of the burden of implementing the law to the states.

As NPR's Julie Rovner reports, the clock is now ticking.

JULIE ROVNER, BYLINE: States are actually responsible for the lion's share of getting people without insurance covered under the new law. First, they get to decide whether or not to set up, and run, a marketplace called a health insurance exchange. That's where individuals without insurance, and small businesses, will go to compare plans and buy coverage. Alan Weil heads the nonpartisan National Academy for State Health Policy. He says yesterday's action will likely prompt a number of states who've been waiting for the court to rule, to get moving.

ALAN WEIL: There are many states that will look at this opinion and realize that if they do not build their own health insurance exchange, or take other steps to implement the law, the federal government will come in and do it for them. And for most states, that's not going to be very palatable.

ROVNER: So far, only about a dozen states are well into the process of planning their exchanges. Weil says states have until this November to decide whether to run their own, or let the federal government do it for them. Either way, he says, there's a lot of concern about whether the exchanges will be ready when enrollment is supposed to begin a little more than a year from now.

WEIL: This is a complex law. The health-care system is complex. The task of finding 35 million people, and determining them eligible for a program, and giving them options, and figuring out the right place for them, is not something we are going to get right the first day.

ROVNER: Then there's Medicaid. The law calls for states to extend the program to everyone with incomes under 133 percent of poverty - about $15,000 a year. That's about 17 million more people. Almost no one thought the court would respond to the states' arguments that the federal government was coercing them into the Medicaid expansion. But that's exactly what the justices did.

Rather than strike down the law's huge expansion of Medicaid, however, the justices simply said that the federal government couldn't take away the rest of a state's Medicaid funding if it doesn't agree to add the new people. Sara Rosenbaum, a Medicaid expert and law professor at George Washington University, says she doubts very many states will end up declining to take part in the expansion. For one thing, unlike the rest of Medicaid - where the funding is shared - in this case, the federal government is paying almost the whole bill.

SARA ROSENBAUM: Free money. It's free money to cover the very poorest Americans, most of whom are working adults. That's why they weren't eligible before.

ROVNER: But there's another reason states may feel the need to participate. It turns out that many of those low-income people who aren't currently eligible for Medicaid, won't be eligible to participate in the health insurance exchanges and get federal subsidies, either.

ROSENBAUM: That in order to go into the exchange, your income has to reach a certain threshold. You have to, essentially, be poor, but not as poor. The Medicaid program is where we're going to subsidize care for the poorest people.

ROVNER: So if a state doesn't expand Medicaid, she says, those people will be left high and dry, and with their state's leaders to thank.

ROSENBAUM: I think almost no state in January 2014 wants to be in the position of having to explain to the rest of the country why its poorest citizens can't get any coverage.

ROVNER: But expanding Medicaid is unpopular in many states, particularly when it's seen as taking money away from programs like transportation or education. Still, even Paul Clement, who argued the case on behalf of the 26 states who fought the Medicaid expansion, says he thinks most states will end up going along with the Medicaid expansion.

PAUL CLEMENT: Since there's all that new money sitting there, and it's all going to be paid for by federal tax dollars whether or not the states accept it, it's still going to be very hard, I think, for the states to refuse the funds.

ROVNER: But the Supreme Court says the states will legally now have the option.

Julie Rovner, NPR News, Washington.

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