Don’t Blame John Roberts for the Medicaid Mess


The New York Times notes today that lots of poor people won’t benefit from Obamacare because the states they live in have rejected the Medicaid expansion that was part of the law. Matt Yglesias comments:

Something that’s worth noting here more prominently than they do is that this is not an oversight of the law or of the Obama administration. It’s due to the actions of Chief Justice John Roberts and then to a number of Republican Party state and local elected officials….The authors of the law decided to make state governments an offer they couldn’t refuse—on the one hand, expansion would be nearly 100% paid for by the federal government while on the other hand failure to expand would come with significant financial penalties.

Then came Roberts. In his landmark ruling upholding the constitutionality of the individual mandate, he burnished his conservative cred by striking down the penalties portion of the Medicaid expansion.

I think this is unfair. In fact, there were only two justices who upheld the Medicaid expansion (Ginsburg and Sotomayor). All the rest, including the liberals Breyer and Kagan, struck it down. So it wasn’t even a close call. The vote against the Medicaid provision was 7-2.

And as much as I dislike the result, I can’t find a lot of fault with this. The basic holding was simple: given our federalist structure, states can’t be forced to help fund new federal programs like Obamacare’s Medicaid expansion. They have to be given a genuine choice. If rejecting the program merely means losing the benefits even though your state’s income tax dollars are helping to fund it, that’s a tough choice, but still a real one. Conversely, if you’re threatened with losing not just the funds for the expansion, but your entire existing Medicaid program, it’s not a real choice at all. Nobody could even dream of doing that. In practical terms, you’re being forced to accept the expansion and you’re being forced to pay for it with state dollars.

I can’t find a problem with that logic. I don’t like it, since my personal preference is for more federal control over national policies, but given our laws and constitutional structure, it’s hard to argue with. If Congress really wanted Medicaid to apply universally, they should have federalized the program and funded it completely out of federal dollars. That would have been unquestionably constitutional. But they didn’t.

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