View From Washington

How Will the Supreme Court Ruling on the ACA Impact MCH?

By Brent Ewig, MHS
Director of Public Policy & Government Affairs, AMCHP

Now that the dust has settled around the long-awaited Supreme Court ruling on the Affordable Care Act (ACA), we have a little more insight and analysis on what the ruling means for MCH. For kids, it is clear that their eligibility was not changed by the ruling. But for women – particularly very poor women – the impact appears to be potentially far reaching.

Within the court ruling was the surprise finding that the penalty in the law for states not implementing the Medicaid expansion was unconstitutionally "coercive." The practical effect is that the seemingly once mandatory Medicaid expansion for all Americans under 133 percent of poverty is now optional. The law did not foresee this possibility and therefore does not include exchange subsidies for individuals under 133 percent, creating a potentially substantial group of very poor people who will remain in what has been called a "no man’s land" or "donut hole" of continued un-insurance.

It remains unclear how many states will decide to opt out, but clearly there are large political and financial stakes that are driving that debate. One nonpartisan source tracking this issue is the media outlet American Health Line. As of Sept. 12, they are reporting that six states are on record as saying they will not expand Medicaid and five more are leaning against. Their state-by state tracker is available here.

Because states receive full federal financing for this expansion for the first three years, states considering opting out are contemplating leaving huge amounts of federal funding on the table. But because the state portion of shared financing goes up over time, it is clear that several states are balancing concerns about their future fiscal obligations. As always, the Kaiser Family Foundation has good additional resources on these issues available here.

The most immediate impact of opting out of the Medicaid expansion would be the implicit perpetuation of a system that only values poor women’s health when they are pregnant and therefore eligible for Medicaid coverage. It is a step back from the realization that the best way to improve women’s health – and by extension the health of her children should she choose to become pregnant – is to focus on those risk factors that affect birth outcomes both before and between pregnancy. It limits the window of opportunity to reverse years of unhealthy behaviors and exposures to several months and, for many women, will perpetuate a situation where they lose Medicaid coverage 60 days postpartum. Again, limiting the ability to address any risk factors discovered during pregnancy and especially those that may have contributed to a poor birth outcome. In short, it would perpetuate a fragmented, episodic approach to health care rather than the continuous and coordinated approach championed by MCH professionals.

So while the opt out option creates or perpetuates challenges, one thing worth noting from our public health science is that health insurance coverage – while fundamental and essential – is insufficient to improve population health outcomes. The preconception care movement also tells us that focusing on prenatal care alone might simply be too late. As one wise state MCH director taught me, "We are realizing that seven or eight months of world class prenatal care simply cannot reverse a lifetime of unhealthy behaviors and environmental exposures that contribute to poor birth outcomes."

Accordingly, AMCHP will continue to advocate that our best opportunities to improve birth outcomes and prevent infant mortality likely comes from focusing on upstream interventions across the life span that prevent or mitigate the chronic disease and other risk factors that might cause poor health and poor birth outcomes. We will keep up our mantra that healthy kids start with healthy moms, in healthy families, in healthy communities. And as always, we thank you for providing the commitment and leadership we need to accelerate progress.