post by Paul Kelleher
Earlier today I quoted Chief Justice John Roberts' opinion on the Affordable Care Act in which he, writing for a majority, argued that the law unjustifiedly "put a gun to the head" of states. This was in response to the federal government's power, under the ACA, to threaten to withhold all Medicaid funds from states that refused to participate in the ACA's expansion of Medicaid. I asked why SCOTUS sided with the states on this issue, when the flipside is that without Medicaid expansions, some people will face "guns to the head" in the form of serious illness or even death.
This was too quick on my part. I should have acknowledged that moral assessments of similar outcomes can nonetheless diverge because of how they came about. For example, I bear a stronger duty to give you one of my kidneys if I was the negligent cause of your renal failure than I would bear if I had nothing to do with your unfortunate predicament. Likewise, the court seems to be saying that it is wrong to actively make it the case that states have "no choice" but to expand Medicaid, but it is not wrong to merely refrain from aiding unfortunate others.
Characterized this way, I think the better way to question the Court's logic is to note that its decision displays special concern for the autonomy of states without acknowledging the special costs this may have for the autonomy of those who will remain without coverage. The whole point of offering low income folks access to Medicaid is to give them options and choices they would otherwise not have. To do this, Congress chose to curtail the autonomy of states by making access to Medicaid funds contingent on expansion. Is this wrong? To show that it is, one needs to explain why it is wrong to balance states' autonomy against the autonomy of folks who face sickness and death without any recourse for adequate treatment or palliation. But the Court didn't do this. It simply pointed to the fact that states stand to lose 10% of their budgets if they don't expand, and it declared on that basis that ACA permits unconstitutional coercion. I simply think this reasoning is much too quick, and that those who might remain uninsured are owed an explanation of why their diminished capacity to choose cannot justify diminishing that of states.