Point of View

The Southern side of health coverage

July 7, 2012 

  • By the numbers 17 The percentage of Americans who have no health care coverage 27.6 The percentage of Texans who are uninsured 23 The percentage of Mississippi and Florida residents who are uninsured 20 The percentage of North Carolinians who are uninsured 4 The percentage of Massachusetts residents who have no health insurance

I begin with a word of unfeigned praise.

Readers of these pages can attest I’m no consummate fan of John Roberts. I’ve greeted his opinions with a fair share of criticism. Perhaps more than a fair share. Still, I’m pressed to say that his decision to provide the fifth vote to uphold the Affordable Care Act was a move of unforeseen and almost unparalleled statesmanship.

Unforeseen because the Supreme Court has split 5-4 over a hundred times since Roberts became chief justice. The health care case was the first and only time, under such divided circumstance, he sided with the moderates. A notable departure.

Unparalleled because of the character of the choice. No doubt millions are infuriated by Roberts’ seeming reversal. And it is possible, I concede, that his conclusion is mistaken as either constitutional interpretation or public policy.

What is certain, though, is that Roberts cast aside personal predilection and ideological predisposition in favor of what he believed to be overarching institutional and national interest. As I said, there’s no guarantee he got it right. But it is now so exceeding rare to see an American leader place national interest above personal preference that one is required to note it. Even if he is not otherwise a brother in arms.

To broader and more contentious fare:

As the Supreme Court upheld the health care bill’s mandated coverage, seven justices placed ample constraints on the program’s massive Medicaid expansion. They ruled that Congress had exceeded its authority by coercing states to participate through the threatened loss of existing federal payments.

Accordingly, states can now choose to forgo new dollars, and new strings, without abandoning Medicaid coverage (and funding) altogether – a prospect none could realistically abide. States have a choice whether to assist in providing additional health care services to their poorest citizens.

The resulting political donnybrook may be a daunting one.

The federal “offer” is breathtakingly generous. The national government, for several years, will pay all the costs associated with expanding Medicaid to reach those living at up to 133 percent of the poverty level. The states’ share of expenses then slowly rises to a maximum of 10 percent, by 2020. Some deal. Your citizens get the health care; the feds pay well over 90 percent of the tab.

Still, an array of states are cranky. A number sued, of course, to try to stop the augmented Medicaid program in its entirety. Failing that, they now object to any proffered marriage. Gov. Nikki Haley is perhaps illustrative: “We’re not going to shove more South Carolinians into a broken system that further ties our hands.”

The stakes are telling. In writing the health care bill, Congress assumed the poorest would gain coverage through Medicaid. Those with higher incomes get subsidies for private insurance. If a state opts out of expansion, many of the poorest will be unable to get either Medicaid or the subsidy. Offering the least to “the least of these.”

Haley’s objection is representative in another way. She leads a Southern state. Phil Bryant of Mississippi vows he’ll “resist any expansion of Medicaid that could result in … tax increases or cuts to job creation.” Bobby Jindal in Louisiana explains this is “why we refused to implement Obamacare or the Medicaid expansion.”

Rick Scott of Florida rejected more than $100 million to implement the health care bill. Rick Perry in Texas moaned: “Now that the Supreme Court has abandoned us, we must take action at every level of government (to save) our liberty.” Doesn’t sound promising.

What’s odd about this is how much, under the program, the South has to gain. Nationwide, 17 percent of Americans have no health care coverage. In the South, that number seems like nirvana. The new, comprehensive Gallup study revealed an astonishing 27.6 percent of Texans are uninsured; 23 percent in Mississippi and Florida; 22 in Arkansas, Oklahoma and Georgia; 20 in Louisiana, North Carolina and South Carolina; 19 in Alabama and Kentucky.

Massachusetts, on the other hand, thanks to Gov. Romney, has 4 percent uninsured.

The South is the native home of American poverty. We have more poor people, and more politicians unfazed by it, than the rest of the nation. Ever has it been so.

James Madison would be surprised by such political turns. How does it happen, he’d ask, that states whose citizens would benefit the most from a significant program wage unsheathed war against it – turning away lifesaving aid to their most vulnerable citizens?

The answer is the ascendancy of a politics in which poor people don’t count. It, too, whistles Dixie.

Gene Nichol is the Boyd Tinsley distinguished professor at UNC’s Law School and director of the UNC Center on Poverty, Work & Opportunity.

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