While upholding the most hotly debated part of the health care overhaul law — a requirement that most Americans have health insurance or pay a penalty — the Supreme Court said in its ruling on Thursday that states did not have to expand Medicaid as Congress had intended — leaving a huge question mark over the law’s mechanism for providing coverage to 17 million of the poorest people.

In writing the law, Congress assumed that the poorest uninsured people would gain coverage through Medicaid, while many people with higher incomes would receive federal subsidies to buy private insurance. Now, poor people who live in a state that refuses to expand its Medicaid program will find themselves in a predicament, unable to obtain either Medicaid or subsidies.

That potential gap will probably lead to ferocious statehouse battles in the coming year, as states weigh whether to accept billions of dollars in federal aid to pay for expanded coverage. The health care industry, sensing the skepticism in some states, is preparing a campaign to persuade state officials to accept the money for coverage of the uninsured.

But already, governors in Kansas, Nebraska and South Carolina, among other states, have said they would have difficulty affording even the comparatively small share of costs that states would eventually have to pay.

Gov. Dave Heineman of Nebraska . . . indicated that he was against expanding Medicaid eligibility.
“As I have said repeatedly, if this unfunded Medicaid expansion is implemented, state aid to education and funding for the University of Nebraska will be cut or taxes will be increased,” Mr. Heineman said.

In South Carolina, . . . a spokesman for Gov. Nikki R. Haley, said, “We’re not going to shove more South Carolinians into a broken system that further ties our hands when we know the best way to find South Carolina solutions for South Carolina health problems is through the flexibility that block grants provide.”

In New Hampshire, State Representative Andrew J. Manuse said he and other Republicans were already working to block the expansion of Medicaid. “We can’t afford it,” Mr. Manuse said. “It’s as simple as that. Thank God the Supreme Court gave us an option.” "


It's going to take lots of money, and money we don't have at the ready, to insure more people with greater coverage, keep our various governments functioning, keep our public education system from falling apart and continue to pay "unfunded" retiree benefits for Social Security and public sector workers. And then there's Medicare, Medicaid and countless other underfunded government knows best programs as well. And while we're at it, let's not forget the post office, Solyndra and others.

My best guess is that reality will now begin to take center stage in the public discussion. How will we pay for all these goodies, admitting that they're all "nice-to-haves?"

We will now have to make choices about what's "nice-to-have" versus what's "necessary to have?" What we're willing to pay for, in other words.

The days of the free lunch are coming to an end, both here and in Europe.

So my overall take on the week's events is that a very healthy, necessary and long overdue national conversation is beginning.

And although perhaps initiated by the Supreme Court's decision about the "Affordable Care Act," the discussion will go far beyond that ruling.

A few of the discussion items will consist of the following: How big of a government, how to pay for it, what about the young versus old, public sector versus private sector benefits, emphasize private sector economic growth or government growth, how "progressive" will the tax system be, what rights will the states have, will we acknowledge that the federal government in fact has no money to share with the states, and countless other things.

In my opinion, this is all good stuff for We the People to discuss and decide. It's what self governing people should do. 

Thanks to President Obama, the Affordable Care Act, the Congress and the Supreme Court, we're in for some very interesting times --- and choices, too.

Just as it should be.

Thanks. Bob.