Maybe the Supreme Court didn’t do President Obama any favors by upholding two of the three major provisions of the Patient Protection and Affordable Care Act (PPACA) (P.L. 111-148 ) in National Federation of Independent Business v Sebelius. By ruling that the federal government could not withdraw all funding from a state’s Medicaid program if it refused the Medicaid expansion, the Court removed one of the three legs that supported PPACA. As a result, the low-income, uninsured residents of states where opposition to PPACA (and, perhaps, to President Obama as well) is most intense will be stuck in a coverage gap—they won’t qualify for Medicaid because their incomes are too high, but they won’t be able to buy coverage on the health insurance exchange because their incomes, at or below 100 percent of the federal poverty level (FPL), are too low.
As it happens, many of these states also have the highest percentage of low-income, uninsured residents. On average, 15.5 percent of the nation’s population is uninsured, but in Florida, 21.3 percent of the population is uninsured, 19.7 percent are uninsured in Georgia, 18.2 percent in Mississippi, 17.5 percent in South Carolina, and 23.6 percent in Texas—the highest in the nation. And one in three residents of South Carolina and Texas have incomes at or below 138 percent of FPL, which would make them eligible for Medicaid if the state expanded. And many of the states that refuse to expand Medicaid also have higher rates of colon cancer, breast cancer, and other preventable illnesses. Still, governors and legislators in these states refuse both Medicaid expansion and the opportunity to run the health insurance exchanges. And at both the state and federal level, they do whatever they can to stop PPACA. The Republican-controlled House has voted to repeal it 37 times, and most recently, has proposed to withhold funding for implementation of the health insurance exchanges.
Congress passed the legislation to create Medicare and Medicaid in late July 1965, and President Lyndon Johnson signed it into law on July 30, 1965. The federal government managed to overcome hostile opposition to the law and coverage began less than one year from the date of enactment. As the principal actors described in a 2001 publication, during that one year, federal workers went door-to-door to tell elderly citizens about the law and help them to enroll. The Social Security Administration (SSA), with the help of the General Services Administration, added hundreds of district offices and hired thousands of people. The SSA entered into contracts with insurers to act as intermediaries. People who were eligible for Medicare but not receiving Social Security benefits had to enroll by March 31, 1966. By mid-summer, 1966, 93 percent of people eligible for Medicare were enrolled.
There was vocal opposition to Medicare, particularly from physicians, who warned that it was the first step toward socialized medicine. Yet, the agency made compliance with the Civil Rights Act of 1964 , i.e., racial integration of hospitals, a condition of Medicare participation. Using staff from the Public Health Service and state health agencies, it surveyed hospitals for compliance. A promise of future compliance with this requirement was not acceptable. The hospitals had to demonstrate that they were integrated during physical inspections by surveyors. And they did so because they wanted Medicare payments.
Could a Health Care Program Be Implemented in One Year Today?
There are many more obstacles, both political and institutional, that would probably prevent the accomplishment of such sweeping change today. That one party controlled both houses of Congress and the White House certainly helped. But there are several other obstacles to implementation in the 21st century that did not exist in 1965:
- More levels of management in each agency. More people have “turf” to protect and their own agendas.
- More statutory restrictions on agency action. Although the notice and comment requirements of the Administrative Procedure Act existed, there was less emphasis on compliance with procedural requirements, in part, because the agencies negotiated on timetables for compliance on issues other than integration. The Regulatory Flexibility Act and the Paperwork Reduction Act did not exist yet.
- No litigation. Nobody sued to challenge the law or its implementation.
- Trust and cooperation among agencies. When SSA gave the GSA a timetable to find space for hundreds of offices, the GSA accepted it and acted on it. Staff from the Forest Service went into the woods to sign up “hermits.”