On June 28, the two-year legal challenge brought by Florida and 25 other states to the Affordable Care Act (ACA), reached its dramatic conclusion with a (split) decision by the U.S. Supreme Court. In two sentences, what did the Court decide?
They upheld the entire Affordable Care Act (ACA) as constitutional*. So the ACA is the law of the land and is fully in effect.
Why the asterisk (*) though?
The Court did identify one problem related to the Medicaid expansion component of the ACA that would make most Americans up to 138 percent of the poverty level Medicaid-eligible as of 2014. Because the expansion is such a significant change to the Medicaid program, the Court said, it would be unconstitutional for the feds to enforce an older Medicaid law that would have allowed withholding of all federal funds for a State's existing Medicaid program if it refused to expand. Bottom line: Florida can't beforced to expand Medicaid (but see below).
When Governor Scott stated his intent not to do anything to comply with the ACA, what was he talking about?
Although it seems unlikely that the Governor has any immediate plans to change his practice of rejecting all ACA-related funding and taking no action to implement the law, he was mainly referring to two main ACA components. First, he said Florida would likely: 1) not expand Medicaid, and 2) not launch a Florida-based Health Insurance Exchange where Floridians could find and buy quality, affordable coverage - with assistance available to households up to 400% of the poverty level to ensure affordable coverage.
Was the Governor specifically threatening to break the law or ignore federal authority?
Although the Governor appears ready to break his pledge to implement the law if upheld by the Supreme Court, so far he has not discussed anything that would be illegal. Here's why:
1) As a result of the Supreme Court's decision, Florida could reject Medicaid expansion without fear of losing federal funding for its current Medicaid program. So such a decision would be legal, but extremely foolish. Medicaid expansion would provide desperately-needed coverage for a million very low-income Floridians, while bringing in almost ten federal dollars for every State dollar invested in the next decade.
2) If Florida did nothing to set up its own "state-based" Exchange, Floridians would still have access to a "federally facilitated" exchange. That wouldn't necessarily mean that the federal government would run the whole thing. The Exchange could take the form of a federal-state partnership, where the state would perform some function and the feds perform others.
Who will make the financial decision about what to do and by when?
If the State plans any involvement in the initial operation of an Exchange - either on its own or as part of a federal-state partnership - it would need to tell the feds in writing and submit a detailed plan by November 16. The Exchange must be ready to perform a wide array of complex functions by next fall, and Florida is still at "square one." Significant federal involvement seems inevitable. The Legislature will have a say, but unless there is a special session, their input may come too late, at least for Round 1. As for Medicaid expansion, the Legislature could decide that question next spring, but that really doesn't allow enough time to prepare, even if the feds determine eligibility.
