The Supreme Court rejected the Patient Protection and Affordable Care Act (PPACA) provision that would have required states to expand their Medicaid programs, leaving the Secretary of the Department of Health and Human Services (HHS) with limited power to shape Medicaid policy at the state level, according to an article published in the August issue of Health Affairs.

In its majority decision to make Medicaid expansion voluntary, the court essentially ruled the provision to provide coverage to all individuals living at or below 133 percent of the federal poverty line to be a transformative program separating it from the Medicaid program as it currently exists.

“Until the PPACA, federal law did not provide general eligibility for low-income people who did not fit into one of the named categories--specifically, low-income adults without dependent children,” wrote Sara Rosenbaum, JD, chair of the health policy department at the George Washington University School of Public Health and Health Services, and Timothy M. Westmoreland, JD, a law professor at the Georgetown University Law Center.

The expansion provision was deemed transformative by the court, as evidenced by Chief Justice John Roberts’ opinion, because it applied to a group previously unrepresented as a recognized eligibility group category under existing Medicaid law. This means that other Medicaid-related provisions of the PPACA, such as one requiring all states to complete enrollment of all minors living at or beneath 133 percent of the federal in Medicaid, still stand.

While expansion is no longer enforceable as a mandate, the PPACA still partially accomplishes its goal of expanding coverage through Medicaid, but HHS Secretary Kathleen Sebelius is left with limited power to encourage states to expand their Medicaid programs.

“The court’s decision strips the secretary of the power to require states to expand their Medicaid programs,” Rosenbaum and Westmoreland wrote. “If the states do not meet the terms of the PPACA and Congress does not change them, the practical effect is to leave the secretary with limited powers other than demonstrating flexibility to spur action.”