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Boston College Law School




Both pillars of the Affordable Care Act that are designed to facilitate universal coverage — the low-income tax subsidy and Medicaid expansion — have been subject to high-profile Supreme Court cases. While in King v. Burwell the Court saved the ACA’s low-income subsidy, in NFIB v. Sebelius the Court frustrated Medicaid expansion, at least temporarily. We argue that there is a deeper story about health care access for the poor. Drawing from the history of the American health care system, vulnerability theory, and demographic data, we demonstrate that all Americans lead subsidized lives and could find themselves quickly moving from the private to the public system. We contend that the apparent political preference for private, or “hidden,” government assistance over public, or “visible,” government assistance has its roots in the American myth of self-reliance. Our analysis debunks this myth and reveals that the line between hidden and visible government assistance fails both theoretically and empirically. We conclude that a single government program for the poor would be more economically and administratively efficient.

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