By noon eastern this Thursday, June 28th, the Supreme Court of the United States will decide the constitutionality of the Patient Protection and Affordable Care Act (ACA). This will not be the last time that this issue will be decided or challenged, as some type of health care reform is inevitable and Congress is committed to stop funding of a myriad of elements included in the law.
The choices for the court are complex but also quite simple:
- Uphold whole the Law
- Repeal the whole law
- Repeal the individual mandate to buy insurance, or parts that are affected by the individual mandate
- Repeal the Medicaid expansion
Each of these options has its own sets of complexities.
If the whole law is upheld, it will still be challenged by Congress, funding could be thwarted, and the law still changed dramatically. Many states are nowhere near where they need to be on establishing the insurance exchanges. Moreover, the costs associated with implementing this law are very expensive and will require significant participation and agreement from many parties.
If the whole law is repealed then the issue of healthcare reform again comes to the front and center of the political debate. Many of the programs could come to an abrupt halt or at least discontinued once the current funding runs out. Both Romney and Obama will likely spend significant resources during the presidential campaign to defend the law or offer new ideas and solutions depending on the Court’s outcome. While the economy and jobs will still likely be the key issue for voters, health care reform is extremely important for certain demographics such as the elderly, 18-26 year olds, women, and individuals with chronic and rare diseases.
Repeal of only the individual mandate will cause all sorts of troubles for the law itself. Many of the assumptions to pay for the popular elements of the ACA, such as insurance for dependent children until they are 26, guaranteed issue of insurance for those with preexisting conditions, and the elimination of coverage limits economics, were based on the mandate. If the mandate is struck, it is uncertain how these pieces could remain as well. Also, there will have to be some sort of special master assigned by the Court to determine what stays and what goes in the law as it relates to or depends on the individual mandate.
Repealing Medicaid Expansion is the least likely scenario, but if the Court does, where will these 18 million patients fall into the system? Will they now be forced to purchase insurance if the individual mandate is upheld? These are still unanswered questions.
Changes are Here to Stay
Even if the ACA is repealed, there has been culture change in medicine and health care at the top, which is likely to stay within our health care system for years to come.
Employers and payers, both private and public, are demanding that we find ways to reduce the overall cost of medicine. Health care reform demands more coordinated and patient-centered care, with an emphasis on quality and accountability. Greater scrutiny to payments will become more and more prevalent and will include the cost for all parts of the system. New mechanisms to fight fraud, waste and abuse in federal health care programs likely will remain untouched by the Court’s decision, and the emphasis by the Department of Justice and the Inspector General of the Department of Health and Human Services on these areas will remain firm.
As stakeholders in the health care system move forward, organizations will have to evaluate whether their services are providing value to patients. In fact, some of the changes to the way we think about paying for healthcare, providing quality care, and coordination of care are upon us quicker than the private sector would have adopted them.
Private and public payers are committed to prevent cost increases once and for all. Hospitals, health care providers, and manufacturers are now focused on improving care at reduced costs. The concept of coordinated care is now being driven by patient centered medical homes and accountable care organizations. These models are here to stay and will continue to expand regardless of the outcome of the Supreme Court decision on the Affordable Care Act. For example, “There are now something like 50-plus ACOs in Medicare alone,” said Dr. Mark McClellan, who ran Medicare under President George W. Bush. “There are probably 250 nationwide — not just public but private. No question the Medicare legislation on this issue has led to more adoption of these payment reforms.”
Regardless of the outcome, the health care reform debate has changed the way we think of healthcare, and some of those changes are here to stay.