WASHINGTON—Following last week's Supreme Court ruling upholding the Affordable Care Act (ACA), the focus is now on the states and how they'll react to the law's Medicaid expansion and health insurance exchanges reported MedPage Today.
"States are now Ground Zero for health reform: the law puts enormous pressure on states to act quickly and decisively," Paul Keckley, executive director for Deloitte Center for Health Solutions, wrote in a Friday memo. "Should they implement an insurance exchange, or default to a federally run alternative? Should the state's Medicaid program be expanded per the law?"

State Medicaid Decisions Looming
In terms of the ACA's Medicaid provisions, although the Supreme Court's 5-4 decision upheld most of the ACA, it essentially allowed states to opt out of a crucial piece of the law—the provision that expands Medicaid to cover nearly all people under age 65 with household incomes at or below 133 percent of the federal poverty level. That provision is set to go into effect in 2014.
While the court found the Medicaid expansion is constitutional, it ruled that the provision in the law that gives the Secretary of Health and Human Services (HHS) the authority to financially penalize states that don't comply with the expansion—by withholding federal Medicaid matching funds—is not constitutional.

Robert Laszewski, a consultant and former insurance executive, said in a statement that the major focus is going to turn to the states that opposed the ACA.

"Now, conservative governors who said they wanted no part of a Medicaid expansion shoved down their throats from Washington have the ability to opt out of it without a penalty," he said. "That puts those conservative governors and their legislatures on one big hot seat. Whether or not their state gets a Medicaid expansion is now entirely up to them. It's put up or shut up time for conservative governors and state legislators who said the ACA was an onerous expansion of federal powers over their states."
Put another way, without fear of being penalized, will states that oppose the ACA be compelled to expand their Medicaid programs?
Health policy experts are betting yes, they will.

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