Last summer the Supreme Court, led by Chief Justice Roberts, ruled that the Affordable Care Act was constitutional and cemented in the legislation.  This pretty much ensured full implementation in 2014.  They did overturn one significant piece of the legislation, which involved the expansion of Medicaid for those who currently fell just outside the limits of coverage.  The Court said the federal government couldn’t force states to cover these new enrollees even though the states would pay nothing at the beginning and would never have to pay more than 10% of the costs for these extra patients.  In so many ways, it was a huge benefit for the states but the Court didn’t like the “heavy-handiness” in the legislation.

Since that ruling, the states have had huge debates as to what they will do relative to this Medicaid expansion.  Some have accepted the deal and some have completely denied the offer from the federal government.  Many states are still on the fence, with significant arguments taking place between governors, their legislatures and their healthcare community.  It will be very interesting to watch over the coming months what happens as the real deadline approaches.  Will states really leave the “free money” from the federal government on the table and force the uninsured to continue to seek medical care in hospitals as they have in the past?  If half the states don’t accept the money does that mean the other states will benefit because they will be using everyone’s tax money to help in only half the states?

What the Supreme Court has done, and it was clearly not their intention, was to set up a grand experiment.  Through their ruling and the subsequent actions in the states there will be two classes of medical care in our country, those with more coverage and those with less. It is very important to point out, and I think this confuses many, that the Affordable Care Act will impact every state and every person, whether or not the states agree to participate in the Medicaid expansion deal.  They will still pay the extra federal tax and still have to comply with all other parts of the legislation.

To see how these states break down take a look at the graphs in this Huffington Post piece that show the current status of each of the states and the level of uninsured in each state.  Before looking, write down on a sheet of paper the 10 states you think have the best medical care in our country and the ten worst.  If you are a real policy geek look around the Internet to support your thinking with data.  Where are the best teaching hospitals?  Ok, now look at the list and compare your thinking with what is going to happen.

The real concern with this “Supreme Experiment” is that the states that need the help the most are the ones who are refusing the financial help and the expanded coverage.  It will be very interesting to watch how this all plays out, but it is quite concerning that the experiment is being conducted on the vulnerable uninsured in our country.  Keep in mind that this group is not the poorest in our country, as those folks are already and will continue to be covered by the current Medicaid program.  In many cases this new group could be viewed as the working poor, in that they make too much money to be covered by Medicaid and yet can’t afford to buy their own insurance.  Reform is definitely messy and it takes a lot of hard work and compromise.  I hope policy makers on both sides recognize the stakes in this experiment and as the results unfold modify with the country’s health being the most important parameter.