First, the Medicaid “coercion” decision should initiate an interesting political debate. Should those states calling most loudly for repeal/overrule of the ACA now be true to their convictions and walk away from Medicaid expansion? To do so would be a remarkable triumph of ideology over their constituents’ public interest and economic interest. They would be abandoning a large segment of their most needy citizens AND leaving a lot of money on the table (the Federal government will pick up 90% of the cost of the newly enrolled and give other benefits to the states).
The States standing to benefit the most from Medicaid expansion are by and large red states, so the political dynamic will be interesting. As an aside, I’d note the willingness of the Congressional representatives from many of the poorest states to ignore a generous federal subsidy for their indigent citizens by voting against the ACA is a tribute to the gerrymandering that distorts congressional districts and to the influence of our distorted campaign financing laws. Federal subsidies aside, there may be considerable savings to State employee insurance and private insurance as the cost shifting from care to the poor is reduced. (Zeke Emanuel says that California is expected to save $2 billion as a result of Medicaid expansion). All in all its a nice way of putting the ball in the court of the critics and framing the issue pretty starkly: do you want to participate in the shared national responsibility to take care of the less fortunate or is your State willing to leave a sizable segment of its citizens exposed to the dire consequences of being uninsured?
Second, the tone of the opinions was surprisingly moderate. One wonders whether the remarkably vituperative talk about the ACA in the Presidential primaries and on the Hill caused the dissenters to temper the language of their opinions. Perhaps the biggest surprise to me over the last two years has been the ability of opponents to generate enormous anger over the ACA. Removing the “rights” element from the debate might at least calm the waters a bit.