Posted Thursday, June 28, 2012, at 5:23 PM
Read the rest of Slate’s coverage on the Supreme Court upholding the Affordable Care Act.
Suzy Khimm writes that on a press call Nancy Pelosi expressed confidence that states won't want to opt out of Medicaid expansion even though John Roberts says they're constitutionally permitted to do so:
Pelosi argued that it will be extremely difficult for conservative states to opt out once their residents see how other states are benefitting from the Medicaid expansion. “Once this bill is rolling and people experience benefits of it, it’s very hard for a state to say [no],” she said. States will also receive full federal funding for the first three years of the expansion before they have to take up more the expense, which Pelosi described as a major incentive to get them to participate.
I think that's basically right with the—important—proviso that all forecasts have to be conditional forecasts.
If Mitt Romney wins the election, I think he'll just repeal the whole thing and it'll be a non-issue. But assume Obama gets re-elected and it should play out more-or-less the way Pelosi says.
Starting in 2014, most states will start receiving 100 percent federally financed Medicaid expansions. Even in conservative states, doctors and other health care providers will be telling their representatives that turning down free money is stupid. But some states will say no anyway out of ideological zeal. Then comes the 2014 midterms during which some of the conservative governors elected in 2010 will probably lose, increasing uptake. Meanwhile as the new congress starts, Republicans are going to realize there's no way to kick people off an existing health care program. At the same time there will still be the usual partisan clashes about tax and spending levels. Rather than chasing a big picture "repeal" agenda, Republicans will be trying to win specific wins on specific legislative issues. The ACA won't become uncontroversial, but it'll become disaggregated. Rather than talking about "ObamaCare" will be talking about "Medicaid spending" and "capital gains taxes" as separate subjects. That should normalize state level politics and if all that money stays on the table, governors of both parties will reach to grab it.
The real questions, in other words, aren't "will states refuse to expand Medicaid?" they're "will the whole bill be repealed in 2013?" and "will the terms of the offer stay so generous as stipulated in the current bill?" If the answers turn out to be "no" and "yes" then states will gladly play along.