The Affordable Care Act Waiting Game, Part One, Act IV.

The Affordable Care Act (ACA) is the official name for the health reform package that Congress passed in early 2010. For most adults, the full impact of this legislation will not be felt until 2014. In two years, all Americans will be required by law to heave health insurance; in exchange, insurance companies will be forbidden fromm denying coverage to anyone, regardless of previous health concerns.

For millions of children and families however, the ACA's protections are currently providing critical coverage and services. Under the ACA, insurance companies were required to offer insurance to all children immediately, even those children with a pre-exisiting condition. In addition, children and their families no longer have to worry about lifetime caps on medical expenses, young adults can stay on their parents insurance until age 26 and, perhaps most importantly, the ACA offers home visitation services to at-risk families to prevent child abuse and neglect and ensure the healthy development of all children.

In April, the Supreme Court heard arguments regarding the constitutionality of the Affordable Care Act. To better understand these arguments, think of a play in four acts, and please note that Acts I, II, and III were posted last week - here.

Act IV: Did Congress step on the states toes with the expansion of Medicaid?

This is perhaps the most complicated part of the argument, but could potentially have the farthest reaching consequences. In the US, the federal government often uses funding to enact policies that states would not otherwise carry out consistently.

For example, until the 1970's, the drinking age varied from state to state. In an effort to curb drunk driving, the federal government required that in order to receive money to build and maintain roads and highways, states must adopt a drinking age of 21. Although the states could set any drinking age they wanted if they did not accept the money from the government, the incentive was too good to pass up. (Think of it like a teenager who receives a car from her parents only if she agrees to drive her little brother to and from school.)

As part of its efforts to ensure everyone in America is covered by health insurance, Congress expanded the Medicaid program to include significantly more low income individuals, including millions of previously uninsured children.

This program is one in which the states receive money from the federal government which they use to provide Medicaid coverage to their citizens. In order to receive this money, states must pay a portion of the costs and follow guidelines set forth by the government. (To extend the car metaphor, the teenager who received the car is now also responsible for covering some of the cost of gas, including those incurred driving her brother around).

The group of states who brought the case to the Supreme Court claim that the amount of money being offered to extend Medicaid is too great to pass up, but, at the same time, there are too many strings attached. The Supreme Court must decide if, as the states are claiming, Congress' requirements are coercive.

The Supreme Court will issue their decision regarding the ACA any day now, and possibly as early as today. Part Two of this series will examine the potential consequences of that decision on the prevention of child abuse and neglect; and more broadly, the health of children, youth and families today and for generations to come.