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Starr: The Supreme Court Decision As a Political Opportunity

This item is a special guest contribution by Paul E. Starr, Professor of Sociology and Public Affairs at Princeton University, co-founder of The American Prospect, and author of Remedy and Reaction: The Peculiar American Struggle over Health Care Reform.

The Supreme Court decision to allow states to opt out of the Medicaid expansion puts millions of low-income Americans at risk of losing coverage they would otherwise gain under the Affordable Care Act. But while the Court's decision is unjustified as law and policy, Democrats and progressive activists ought to regard it as a tremendous political opportunity to build support and voter turnout in states under Republican leadership.

Under the ACA, the federal government will pay nearly all the cost of newly eligible Medicaid beneficiaries (100 percent for the first three years, declining to 90 percent thereafter). The Congressional Budget Office estimates that the law will increase state Medicaid costs by less than 1 percent.

As the number of uninsured drops, moreover, hospitals will be relieved of much of their burden of uncompensated care and no longer need to transfer that cost to the privately insured. As a result, the Medicaid expansion will be a benefit not just to the poor but to insured middle-class families too, who will no longer pay the indirect tax for uncompensated care that has long been hidden in their health-care and insurance bills.

Besides paying nearly all the cost of the Medicaid expansion, the federal government will pay the entire cost of the subsidies for the near poor and lower-middle-income people who obtain private coverage through the new insurance exchanges. Together, the expansion of Medicaid and the insurance subsidies will bring billions of dollars into states with large uninsured populations. That revenue will strengthen their health-care institutions and have a multiplier effect, increasing jobs in related industries.

In states whose leaders currently threaten to refuse the Medicaid money, Democrats running for office should be able to make a forceful and persuasive case that carrying out health-care reform will be good for the state as a whole. They ought to use these arguments to put middle-income voters at ease about health reform, while mobilizing voter turnout in the low-income communities that will gain most directly. Accepting the federal funds to expand Medicaid will have clear, real-life benefits--for some people, benefits that can make the difference between life and death.

Moreover, this is not a situation where low-income groups and progressive activists will be on their own. Health-care providers will support efforts to persuade state officials to put aside ideology, consider the best interests of all their people--and take the money.

The mostly southern states that are resisting the Medicaid expansion have a long history of denying adequate social protections to low-income people, but there has never been a more advantageous moment for progressive-minded Democrats to organize around that issue. The Supreme Court shouldn't have made the Medicaid expansion optional, but now that it has, Democrats should make the most of Republican block-headedness.