Congress can and should take steps to enact this solution now, which would provide a federal fallback to coverage, just as the act assures a federal fallback exchange system in any state that elects not to set up its own exchange. It is a solution that is consistent with the ACA’s structure, as well as honoring the deeply embedded principles of federalism that guide the federal-state relationship in health care. For those states that continue to maintain Medicaid, federal funding levels could be maintained at 100 percent rather than declining over time, in recognition of their commitment to being full partners in health care.
Sometimes fashioning a remedy to a difficult problem is even harder than the problem to be addressed. This is not the case here. The architecture for a solution is obvious; exchanges go live in a few months, and it is entirely feasible to make them work for the poor in states that elect not to expand Medicaid. Because our solution adheres to federalism while making use of the private insurance market, it should have at least modest appeal to members on both sides of the political aisle.
Despite the partisan politics that have mired the act from the beginning, we want to believe that our leaders in Congress would not look the poorest Americans in the eye and tell them that their plight must continue.
Sara Rosenbaum, J.D., is the Harold and Jane Hirsh professor of health law and policy at the George Washington University School of Public Health and Health Services. Patricia Gabow, M.D., MACP, is the former CEO of Denver Health and a professor of medicine at the University of Colorado School of Medicine.