In a 5-4 ruling yesterday, the Supreme Court handed President Obama a massive political victory, but not as large as many think. By weakening the federal government's ability to expand Medicaid through the states, the court threw health care reform for black and brown America into disarray, and flung half of the law's potential beneficiaries into legal limbo. As a result, the Patient Protection and Affordable Care Act's longterm effectiveness is in doubt, and the racial and economic inequalities at the very heart of the health care system stand to be reinforced. Medicaid--funded jointly by the federal government and the states--is the nation's health care plan for the working poor, those in poverty and their children. Enlargement of Medicaid is the single most important provision of the Affordable Care Act for people of color. It's the way that almost all non-whites covered by the law would receive insurance. If implemented as written, the law expected to cover 32 million Americans, accounting for 80 percent of those currently uninsured. Half of the 32 million are to be brought into the system through Medicaid, and three out of four of those individuals are people of color. As passed by Congress, the Affordable Care Act broadened Medicaid by compelling states to participate under the threat of a severe penalty. Specifically, it would withdraw all Medicaid funds from a state that did not admit more of the working poor into the program. Yesterday's ruling declared that method unconstitutional. But use of similar protocols, carrots and sticks is the way that the federal government has grown Medicaid since its implementation in 1965. Now, states are left to decide what they want to do about the ACA's Medicaid provision without the threat of federal enforcement. And that's a problem, particularly in the Southern, GOP-led states where huge numbers of working poor blacks and Latinos live. The majority of states, due to the recession, want to cover less not more people. There's more demand for Medicaid services and less money to pay for them. As former Republican governor, now Senator Lamar Alexander told The New York Times, "If I were governor of Tennessee, I would not expand Medicaid." Republican Gov. Bobby Jindal of Louisiana echoed the point. Fortunately, other parts of the Affordable Care Act were saved. Most prominent of these is the individual mandate, which hung in the balance too. Without the mandate, two thirds of the nation's uninsured would have remained without coverage and individual health care costs could have skyrocketed 40 percent. Through the mandate, the ACA will make a real difference in the lives of many. But for millions more, the Supreme Court's ruling will only exacerbate inequities at the core of our national health care crisis, and force the battle over the law back to the states. Protracted state-by-state fights over Medicaid expansion will prolong both uncertainty and suffering. It's what's happened since the war over Medicaid began in the mid-1990s, when the Clinton administration began encouraging states to expand the program. The Bush administration came to office and did the opposite, prodding states around the South and the Midwest to come up with inventive ways to kick people out of it. Medicaid remains a bitterly fought over program today. The ruling yesterday will make it more so. For people of color, the impact of the mess that the court just rolled down Pennsylvania Avenue and out into the country cannot be understated. Blacks, Latinos and Asians are up to three times less likely to have insurance than whites. Half of the nation's uninsured are people of color. The Center for American Progress estimates that this racial gap in health care coverage costs the country $415 billion a year in lost productivity. For black and brown America, affordable, quality healthcare is key to closing a wider economic gulf. **Inequity is the Problem** The health care market's inequity--millions in it and millions out of it--necessitates a massive fix. Without correction, the entire system will collapse from the weight of its cost. America spends more of its national wealth on health care than any other country, but covers a smaller percentage of its population. The way our health care network pays for treatment is the root problem. Clinicians are compensated for the number of sophisticated therapies doled out, not for whether they are effective. Patients are in care longer, recovery time is extended, and the overall tab is rising. Trying to keep pace, health insurance premiums are going up at twice the rate of everything else. But America's working poor can't keep up. Almost one million people each year have to drop insurance, because they can no longer afford it. Neither can society as a whole. Medicaid is a mitigating force in this lopsided system. Blacks and Latinos are enrolled in Medicaid at twice the rate of whites. Half of those in the program are children. As the Kaiser Family Foundation has bluntly concluded, "Medicaid enables Black and Hispanic Americans to access health care." The recession has made this more true than ever. Three out of four people who lose their job, also lose their insurance. As a result, the number of people in Medicaid has soared to 60 million. In helping to address the inequality at the heart of the current system, enlargement of Medicaid is key to saving American health care from itself. The Affordable Care Act pays for that growth by transforming the health care delivery network from one centered on fragmented care---where doctors are paid per procedure to treat symptoms--to one which rewards keeping people healthy over the course of their lives. Re-built on the principle of lifelong wellness, this new system would save $2-$3 trillion over 10 years. These savings are passed on to uninsured people in the form of new coverage. By merely keeping people healthy, the law generates enough income to pay for 100 percent of new Medicaid enrollment for three years and 90 percent after that. It would also subsidize up to 95 percent of insurance cost for individuals who make too much to qualify for Medicaid. But all of this presumes states join the effort and expand their Medicaid programs as asked. Given the political landscape, that's an enormous presumption, and yesterday's ruling robbed the federal government of meaningful leverage to force the issue. **The Republican Attack** Republicans latched on to the law's individual mandate to attack Obama's health care plan, but this fight was never about policy, it was about politics. The individual mandate was a Republican idea in the first place. It was first proposed 30 years ago by the Heritage Foundation, a right-wing think-tank, and served as the cornerstone for many Republican health care ideas for a generation. The attack on Medicaid, meanwhile, is far older than the new assault on the individual mandate. In 1995 and 1996, Newt Gingrich shut down the government over Medicaid in an attempt to blackmail Democrats to slash the program. Bill Clinton managed to save and expand Medicaid after rescuing it from Gingrich. It has been a political hot button ever since. Just last year, right-wing congressman and Chairman of the House Budget Committee Paul Ryan submitted a budget that would have effectively ended the program. During the 2009 health care debate, progressive Democrats advocated for a single-payer system based on Medicare. A single-payer system pays for everybody in the country, cleanly and simply. The Affordable Care Act lands us close to universal coverage, but falls noticeably short. If you choke off Medicaid, you choke off any future platform for 100 percent coverage. That's why both the mandate *and* Medicaid were a part of the right-wing legal strategy. Strike a blow to either one and you send the law reeling. In its ruling Monday, the court possibly delivered a surreptitious knock out punch to the Affordable Care Act by making Medicaid expansion far more difficult to achieve. **Democracy Is the Real Patient** Though shocking, the court's move is not surprising. It's one in a string of decisions to sap the government's ability to fulfill its democratic mandate to enact laws in the public interest against the growing strength of corporate power. And the fight over health care has always been just that. As Al Gore said in the 2000 presidential race, it is a classic case of "the people vs. the powerful." Striking down the health care law was the number one goal of right wing groups who poured millions into the Tea Party movement. Two hundred million dollars, in fact. This money elected governors and attorney generals who forced the Supreme Court to take up this case in the first place. "Elections have consequences," President Obama stated in 2009. The fact that the court weighed in on the ACA at all proves his point. With the undisclosed backing of billionaires, on a pledge to "repeal" the health care law, the Tea Party movement swept the GOP to power in 2010. The chief law enforcement officials in Florida and Virginia, lead claimants in the anti-health care case, were both elected that year on a wave of enthusiastic Tea Party support. Ginned up by the ruling, these same political forces vowed minutes after the ruling to continue the fight state-by-state. That's where Medicaid is administered and where they hope to shatter it. The idea that the government would intervene and correct the failure of the health care market is what drove the fringe-minded wealthy--the lifeblood of the Tea Party--to act. Their ire is about politics and not effectiveness. Tea Party billionaires are "Richie Rich" versions of militiamen, those weekenders on the outer limits who worry about black UN helicopters flying over the Midwest, and obsess about a government takeover by the Trilateral Commission. But unlike their camouflaged brethren, they actually have the money, organization, and national reach to put their out-of-the-mainstream views at the center of American political life. Three of the leading anti-health care groups which underwrote the GOP/Tea Party-led backlash--Freedom Works, Americans for Prosperity, and Conservatives for Patients Rights--had backing from endless pools of dark, private money. Freedom Works and Americans for Prosperity are the legacy organizations of the secretive, anti-government, billionaire Koch Brothers. Conservatives for Patients Rights was led by Rick Scott, the disgraced former health care executive who was elected Florida's governor in 2010 on a wave of right-wing, health care outrage. He's currently [engaged in massive voter suppression in that state](http://colorlines.com/archives/2012/06/florida_to_people_of_color_dont_v...). This unified anti-government movement subverts democracy. It wants Americans to forget what is articulated in the Tea Party's own guiding light document, the Declaration of Independence: that in a functioning democratic system the will of the people is expressed through--rather than apart from--the government. In 2008, the American people elected a government with a historic majority which ran on a program of comprehensive health care reform. That government delivered on its promise, according to the rules of the nation established hundreds of years ago. The problem is that a tiny group of powerful billionaires detested the result. As the electorate has become more diverse, elements of the American power structure has shown an increasing willingness to spend millions to de-legitimize it. This rich, organized group stands ready to block laws and policies produced democratically by an increasingly black and brown electorate. The un-democratic nature of their dark money is a truly worrying trend and a way around it must be found. With the court's ruling yesterday, we must not only worry about the health of individuals, but for democracy as a whole. *[Imara Jones](http://colorlines.com/archives/author/imara-jones/) writes about economic justice for Colorlines.com. Follow him on Twitter [@imarajones](http://www.twitter.com/imarajones).*
How the Supreme Court's 'Obamacare' Ruling May Lock in Racial Inequity
Hold the victory celebrations. Yes, the Supreme Court upheld the individual mandate, but it set up a scary fight over Medicaid--which is the half of the law that takes on the deep racial inequity burdening our health care system.
Image: Kris Connor/Getty Images