Under the federal health-care reform act of 2010, largely upheld by the U.S. Supreme Court on June 28, starting on January 1, 2014, Medicaid is to become the usual provider of health care to the poor. Income eligibility limits are key; they now vary widely among states. Many states do the minimum, covering children, the disabled and some parents. [ Income eligibility limits for working adults, Kaiser Foundation, January, 2012, at http://www.statehealthfacts.org/comparereport.jsp?rep=54&cat=4&rgnhl=23 ]

For people with limited incomes, higher than Medicaid limits, states will be expected to provide subsidized private health-care insurance, as Massachusetts began to do under the Commonwealth Care program after the state's own health-care reform law of 2006. Twelve states now provide subsidized health insurance to adults under 65 who earn more than Medicaid limits: California, Connecticut, Hawaii, Indiana, Iowa, Maine, Maryland, Massachusetts, Minnesota, Oregon, Vermont and Washington, plus the District of Columbia.

Massachusetts does not have as much to do as most states to adapt its current programs to the new federal law. Childless adults are currently covered by Medicaid only when employed yet earning very low wages or when recognized as long-term unemployed. Those restrictions must be removed. The new federal income limit for Medicaid is the same as the current Massachusetts limit. Massachusetts will also need to extend its income limit for subsidized insurance from 300 to 400 percent of poverty level. [ Medicaid and the uninsured, Kaiser Foundation, July, 2010, at http://www.kff.org/medicaid/upload/8087.pdf ]

The Supreme Court decision in National Federation on Independent Business v. Sibelius held that the sanction of cutting off all Medicaid payments to states who do not comply with the new law was too severe and could not be implemented. [ U.S. Supreme Court, No. 11–393, June 28, 2012, at http://www.supremecourt.gov/opinions/11pdf/11-393c3a2.pdf ]

However, the Medicaid program has actually carried the so-called "nuclear option" since it was enacted in 1965. That approach has simply never been used. More than likely, case-by-case reviews and perhaps some new administrative regulations will nudge states into compliance in less drastic ways. Similar things have already happened frequently for over 45 years. [ Robert Pear, Uncertainty over whether states will choose to expand Medicaid, New York Times, June 28, 2012, at http://www.nytimes.com/2012/06/29/us/uncertainty-over-whether-states-will-choose-to-expand-medicaid.html ]