In 2012, Chief Justice of the Supreme Court John Roberts delivered the Schrodinger's cat of judicial rulings: the Affordable Care Act that consumed President Barack Obama' first term was both, in part, constitutional and unconstitutional.
Writing for the majority in National Federation of Independent Business v. Sebelius, Roberts upheld the ACA's individual mandate as constitutional, a shock ruling amid heavy conservative opposition to the "socialism" of the measure. But in yet another surprise, Roberts also declared the law's mandatory Medicaid eligibility expansion was an unconstitutional overreach on 10th Amendment grounds, stating that the governors of individual states could determine whether or not to adopt the expansion. The decision offered a perfect moment for the Republican governors who staked their office on their opposition to "Obamacare" to flex their political muscles, and in the years since Sebelius, 13 Republican-controlled state governments—including those of Texas, Florida, and Wisconsin—have opted out of the ACA's Medicaid expansion.
But according to extensive new research, those governors potentially sacrificed thousands of Americans lives in the process of shoring up their political support. Published by the National Bureau of Economic Research, the analysis indicates that the ACA's Medicaid expansion not only resulted in reduced mortality among low-income Americans, but "approximately 15,600 deaths would have been averted had the ACA expansions been adopted nationwide as originally intended by the ACA." Simply put, expanding Medicaid saves lives; restricting it, on the other hand, ends them.
This conclusion isn't necessarily novel, but the NBER research constitutes one of the largest and most comprehensive assessments of the real-world consequences of blocking Medicaid expansion. Drawing on government-collected mortality data and responses to the American Community Survey from more than four million people annually between 2008 and 2013, the researchers deployed various governmental data points like income and citizenship status to "identify individuals who were most likely to benefit from the ACA Medicaid eligibility expansions," rather than just basing a mortality assessment on aggregate death records. The result is, in their assessment, a more nuanced analysis of the actual relationship between Medicaid expansions and mortality.
This number of deaths is a maddening consequence of the Supreme Court's 2012 dance on the ACA, especially given Medicaid expansion significantly helps bolster the financial well-being of low-income Americans. But it's even more maddening when you consider evidence that the measure was the result of jurisprudential politicking. According to long-time CNN analyst Joan Biskupic, Roberts originally rejected the claim in Sebelius that the ACA Medicaid expansion was coercive to states before essentially using the measure as a bargaining chip with liberal justices Elena Kagan and Stephen Breyer for his support on the individual mandate.
First, Roberts "began incorporating arguments that would invalidate the Medicaid expansion," Biskupic reports in her 2019 book The Chief: The Life and Turbulent Times of Chief Justice John Roberts. "This was a strange turn. None of the lower courts that had taken up the ACA had rejected the Medicaid expansion, and it wasn't seen as controversial in terms of constitutional debate and public controversy."
"Breyer and Kagan had voted in the private March conference to uphold the new Medicaid requirement, and their votes had been unequivocal," Biskupic continues. "But they were pragmatists. If there was a chance that Roberts would cast the critical vote to uphold the central plank of Obamacare—and negotiations in May were such that they still considered that a shaky proposition—they were willing to meet him partway."
Roberts' ruling on the individual mandate was hailed as some sort of larger-than-politics threading-the-political-needle, but Biskupic suggests the backroom negotiations over the Medicaid measure constituted the sort of political horse-trading that's purportedly antithetical to everything the Supreme Court stands for. Mother Jones political blogger Kevin Drum encapsulates Roberts' (likely) thinking nicely: "in order to retain his conservative reputation, he needed to strike down something in return for upholding the mandate."
The other maddening element of blocking ACA Medicaid expansion and its subsequent impact on mortality concerns the discourse preceding the Supreme Court ruling. Way back in December of 2009, then-Washington Post economics blogger Ezra Klein caused a small Beltway stir when he lambasted then-Senator Joe Lieberman for threatening to filibuster health-care reform over a separate Medicare expansion. "If there's a policy rationale here, it's not apparent to me, or to others who've interviewed him," Klein wrote. "At this point, Lieberman seems primarily motivated by torturing liberals. That is to say, he seems willing to cause the deaths of hundreds of thousands of people in order to settle an old electoral score."
Many established politicos lost their head over the dastardly implication that not only do substantive policy reforms actually save lives, but those who oppose them over what appear to be purely political reasons deserve responsibility for those lives. Klein "essentially accuses Lieberman of mass murder because he disagrees with him on a policy issue about which there is considerable debate among people of good will across the political spectrum," gasped fellow Washington Post "voice" Charles Lane, adding that "[Lieberman's] position on the Medicare buy-in is hardly beyond the pale."
Killing the ACA Medicare expansion may not have let as many as 137,000 Americans die over six years the way the 2008 Urban Institute study Klein cited suggested, but we do know now that Roberts' decision on the separate ACA Medicaid expansion likely doomed 15,000 Americans.
Make no mistake: Policy saves lives. And while Roberts may have saved the ACA as a constitutional Schrodinger's cat, those Americans who were relying on the Medicaid expansion weren't so lucky—and that responsibility lies, inexorably, with him.
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