The Supreme Court ruling that the Affordable Care Act (ACA) is constitutional moves America closer to basic health care coverage for all citizens. Under the ACA, the federal government will pay 100 percent of the cost of health care for the lowest income citizens (those with incomes of less than $14,850) through expanded state Medicaid programs. For individuals with incomes up to $44,660, the act will provide subsidies to help them buy private insurance.

But the federal subsidy decreases after three years to 90 percent. That 10 percent difference is not a small amount: In Texas, it will be $15.6 billion over 10 years, a recently lowered estimate from the Texas Health and Human Services Commission. Texas' share of the program would cover 1.8 million people who are currently uninsured, costing about $870 per person. It's a pretty good deal since Texas currently pays about $2,000 a person on Medicaid. But Texas still has to find the money.

Or maybe not: Texas does not have to find the $15.6 billion. The Supreme Court has removed the penalty forcing Texas to cover new citizens on Medicaid. If Texas chooses to turn down the Medicaid subsidy, it will solidify its place as having the highest percentage of people without health insurance in the country. This is a real problem that is not going away.

What can be done both by the federal government and by Texas in order to find the money?

First, Texas can keep the 100 percent federal Medicaid subsidy for newly eligible citizens. Second, the federal government can help the states by increasing the amount it pays for all Medicaid patients during times of economic downturns and budget crises.

Such funding could be accompanied by mandatory cost savings initiatives at both the federal and state level as a condition to getting the federal dollars, such as:

A. Paying physicians for quality, a first step that has recently been enacted by the Texas Legislature.

B. Determining which preventive care measures save money, and incent patients to have that care - or create disincentives (yes, the fat tax on high-calorie sodas and food could yield significant revenue).

C. Early use of electronic medical records to reduce billing expense and improve quality.

D. Permitting nurse practitioners to function at the top of their licensure.

E. Using low-cost aides to help care for people at home, reducing emergency department visits and hospitalizations, and helping to keep students healthy and in school.

What should not be done? The U.S. Congress, looking for money, could lower the level of poverty that Medicaid covers and could reduce the subsidies to buy insurance. Under the ACA, Medicaid covers up to 138 percent of the federal poverty level; Congress could decide to fund only up to 100 percent, or $11,170. This seems like a small change, but remember a full-time minimum-wage worker makes $13,920. With that change, a minimum-wage worker will make too much to be eligible for Medicaid, and if the subsidies are reduced, low-income Americans just over the poverty level may find few insurance options that are affordable, thereby perpetuating the access and coverage problems facing the uninsured.

A middle ground might be for federal officials to give states a block grant for their Medicaid programs, thereby encouraging state flexibility. But there is no free lunch and providing some kind of health coverage to the almost 2 million uninsured Texans will cost real money.

So, true, the Supreme Court saved Texas a lot of money in the short term. But will those savings continue in the long run?

