The Supreme Court, Medicaid, and marriage equality: Patterns in state decisions

When the Supreme Court released its United States v. Windsor decision striking the 1996 Defense of Marriage Act yesterday, supporters of marriage equality felt joy akin to what Affordable Care Act supporters felt a year ago when the Court released its decision upholding the healthcare law. Because the Justices dismissed Hollingsworth v. Perry, the case regarding California's Proposition 8, based on lack of standing rather than ruling on the constiutionality of state bans of same-sex marriage, the Court has effectively decided that states get to decide for themselves whether to allow same-sex marriages or not.

This "let the states decide" outcome was also how the Court ruled on the Medicaid expansion provision of the Affordable Care Act: The majority of Justices decided that states should have the option of choosing whether or not to expand Medicaid to all eligible residents with incomes up to 133% of the federal poverty level.

Reading over the list of states that where same-sex marriage is legal, I suspected that most of them are also on the list of states that are taking up the federal government's generous Medicaid expansion offer (federal funds will cover 100% of the costs of these newly eligible Medicaid beneficiaries now, with that percentage dropping to 90% over the next few years). To test my hypothesis, I consulted the Kaiser Family Foundation's table tracking the status of state actions on the Medicaid expansion, which they last updated June 20, 2013. The table classifies states as "Moving forward at this time," "Not moving forward at this time," or "Debate ongoing." The site notes that the federal government has not specified a deadline by which states must decide, so a state that's not moving forward with a Medicaid expansion now might start moving forward in the future.

Here's what I found: Of the 14 jurisdictions (13 states plus DC) that where same-sex marriage is legal, 12 of them are moving forward with the Medicaid expansion; New Hampshire is debating the expansion, and Maine is not moving forward with it. Of the states that don't have marriage-equality laws, 12 are expanding Medicaid and five are debating it. The remaining 20 states have neither agreed to the Medicaid expansion nor passed laws or had court decisions allowing same-sex marriage. Here's what the map looks like:



(My map skills are rudimentary, so this is only the continental US; Hawaii is expanding Medicaid while Alaska is not, and neither has passed a marriage equality law.)

I expect within the next decade or two, all states will adopt marriage equality and the Medicaid expansion. With 81% of adults 18-29 saying same-sex couples should be able to wed, it's only a matter of time before the vast majority of the US population supports marriage equality. (For details on poll results by state, check out Philip Bump's Atlantic post.) Once the Affordable Care Act becomes less of a political flashpoint, it's unlikely to take long before state governments will decide their healthcare providers and uninsured residents could benefit from millions of federal dollars in Medicaid spending and accept the expansion -- or, like Arkansas, they'll try to work out a waiver arrangement under which they can get increased flexibility for their Medicaid program in exchange for expanding eligibility.

Until these changes happen, though, the gulf will only widen between states that extend benefits to more residents and those that deny them. More uninsured people will forego needed healthcare because they can't afford it, or have to choose between medical care and other necessities. More hospitals and other healthcare providers will miss out on much-needed Medicaid dollars. More families headed by same-sex couples will face the constant indignity of knowing their states consider their relationships to be less valid, and will worry about the financial and benefit implications of their unequal status should one partner face unemployment, severe, illness, or death.

Even though I have employer-sponsored health insurance and an opposite-sex spouse, I'm glad my jurisdiction has already taken these steps toward equal opportunities for medical care and marriage.

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