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The Supreme Court's health care decision: What it does—and does not—mean

Source Harvard Health Blog

Anthony Komaroff, M.D., Editor in Chief, Harvard Health Publications

The passage of the Patient Protection and Affordable Care Act (which I’ll just call the Law) in 2010 was regarded as a landmark event in U.S. history. Today’s ruling by the Supreme Court, which largely upholds the Law, should also be viewed as a landmark event—whether one agrees with it or not.

Why? Three reasons: Everyone wants health care when they need it. Everyone wants to be spared financial devastation from the cost of that care. And health care accounts for 17% of the total U.S. economy, and is growing at a faster rate than the rest of the economy—putting the rest of the economy under enormous strain.

Before the Law was passed, I saw two huge challenges facing U.S. health care. The first was the fact that so many people did not have health insurance. The second was the high cost of health care.

For decades, the percentage of Americans with health insurance has been lower than in other developed nations. Passage of the Law did not immediately change things. At the time of a survey by the National Center for Health Statistics in 2011, 46 million Americans—15% of the population—had no health insurance. These people lived an automobile accident, a heart attack, or a stroke away from becoming destitute.

Who are they? Relatively few are unemployed adults. People who are chronically unemployed have often been able to get health insurance through Medicaid. In fact, most of the uninsured are working adults whose employers did not provide health insurance. Many are children—often, the children of employed but uninsured adults. A smaller fraction are adults under the age of 65 who are out of the labor force.

Another group of people without health insurance are healthy young adults who have simply decided not to pay for health insurance—and to take their chances. They know that if they become seriously injured or ill, they will receive health care somewhere—effectively paid for by the insurance payments that other people are making. They are “free riders.” In passing the Law, the President and Congress basically said to them, “That’s not fair.”

What does the Supreme Court’s decision mean?

It means many more people will have health insurance. That does not, however, mean universal health insurance will be provided to everyone.

It means that health care will continue to be provided largely by the private sector—private doctors and hospitals. And for people under age 65, it will largely be financed by private insurance companies, not the government. The charge by some that the Law is “socialized medicine” is simply misinformed.

It means that many very popular provisions of the law will remain in force:

  • Insurance companies won’t be able to deny an individual coverage because he or she has a chronic medical condition, drop coverage if an individual becomes sick, or put limits on the amount of lifetime coverage a person can get.
  • Young adults under age 26 can still be covered on their parents’ health plans.
  • More low-income people will probably be covered by Medicaid, a health insurance program financed by both the federal government and the states

It means that several unpopular provisions of the law also will remain in force:

  • Starting in 2014, individuals will have to pay for health insurance: no more free riders. The Law creates mechanisms that make the cost of health insurance much more affordable for people who don’t have coverage through employers, Medicaid or Medicaire. But nearly everyone will have to pay. That’s the contentious “individual mandate” that many people had speculated would be ruled unconstitutional. It wasn’t.
  • Starting in 2014, many employers who do not currently offer health insurance as a benefit will be required to do so, or pay a stiff penalty.

In summary, the decision of the Supreme Court means that more people will have health insurance. It also means that the enormous uncertainty—for individuals, for employers and for government—about whether the Law would remain the law of the land has been removed. Planning can move forward.

But several major issues remain under a cloud of uncertainty.

Will there be a new President and an altered Congress in January 2013 that might repeal the Law?

Will the constraints on using Medicaid funding that the Supreme Court placed on the Law make it difficult to find the money necessary to provide coverage to everyone the Law intends to cover?

What will be done, if anything, to provide insurance to the millions who will remain uninsured even after the full implementation of this law?

Finally, what will the Law do to contain the rising costs of health care? If those costs continue to rise well above the rate of growth in the economy, it will be damaging to the economy—even if it protects more people from personal financial ruin.

I’m a practicing doctor. I’ve cared for many patients over the years who had no health insurance, and who lived in constant fear for their personal and financial health. So I was delighted that the Law was passed, and am very happy that it has been upheld by the Supreme Court. I’m not cracking open the champagne just yet, though. Although the Law is a major step forward, some major obstacles still remain.

9 comments to The Supreme Court's health care decision: What it does—and does not—mean

  • As a chiropractor there are real concerns that we will be given the crumbs left over. As it stands medicare only covers a person if they have an impairment that can be documented. I understand that 500 billion dollars will be taken from medicare to assist in this program. What I see is more insurances adopting medicare guidelines with increasing premiums and less care as time goes forward. I hope I am wrong.

    • Hi Russell,

      As you well know, there are NO guarantees in life, but…

      • There are a TON of studies showing that Chiropractic Care is MUCH more cost-effective than “usual care” for the things we normally “treat”
      • More Insurers than ever now preferentially steer patients to Chiropractic to capture that savings

      so… NOW, MORE THAN EVER, DCs need to support their National Association (take your pick) so that they have the MONEY required to continue to oversee each step in the ongoing adoption of this Law.

      If you don’t act in your own best interest NOW, who will you have to blame later on???

  • In case you are biting your fingernails, please review this:

    http://www.chiro.org/wordpress/?p=3333

    Among the important changes in the recently passed health reform law is Section 2706, which makes it illegal for insurance companies to discriminate against providers acting within the scope of their state licenses. Predictably, medical physicians who have benefited from many decades of discrimination now seek to turn back the clock and reinstate the pro-discrimination policies that have served them so well for so long.


    READ PAGE 51 of the actual Law:

    http://housedocs.house.gov/energycommerce/ppacacon.pdf


    You may also want to read:

    Health Care Bill Update ~ How It Effects Chiropractic

  • I can tell you that in Arizona many chiropractors have gone out of business because of the new guidelines Blue Cross have levied. Most of my practice is cash now, but the good thing is that patients continue to pay because of their success with chiropractic. When I was involved in a pain group at a local hospital I was asked to lecture them on chiropractic and at my conclusion I said “I see your failures and help 80% of them.” That sent a strong message that continues to be true today.

    • Hi Russell,

      What did the AZ Blues do? Adopt a Medicare rate card? Or hire ACN to take over chiropractic management of claims?

      It’s apparent you figured out what to do…don’t play their game…go cash.

      These Companies compete for business by claiming that they offer alternative/complementary care, provided by DCs. That is only true because DCs sign a contract with them.

      If you signed a Contract, and that Company lowers your rate card significantly, RESIGN YOUR CONTRACT.

  • They hired ACN along with Aetna and Cigna. We opted out of the contract and after being in practice for over 30 years and having good affiliations with other medical providers, I have been able to stay ahead of the political battle.

  • In Alaska we have provider equality. So this isn’t entirely new to us here, and it is nice, I won’t lie. Especially in a state where almost everyone is insured and a cash practice is near impossible.

    My big concern is that I have many patients who aren’t not under care for musculoskeletal complaints. I do battle with their provider for their number of visits, but I wonder how much of the “evidence-based medicine” game will be played in the near future.

    Last thing we need, our patients need, is to hear from insurers that chiropractic can’t help them for things like tinnitus, IBS or MS.

    I still can’t figure out why the law wasn’t a mandate to the insurance industry. Congress already has the power over interstate commerce, and all they needed to do was open up the “borders” and allow individuals and companies the ability to buy insurance over state lines.

  • Enjoy it while you have it. We have to demonstrate an impairment with BCBS before they will pay. Pain is no longer a covered benefit unless they demonstrate some type of impairment.

  • Personally I was pretty amazed that the Supreme Court came back with this decision, but I think it may end up a moot issue. Romney has already pledged to repeal the law if elected, and even if he doesn’t gain office, mandating individuals purchase insurance only works if people can afford to buy it. And if they can’t, the rest of the country picks up the tab for it, which probably means higher taxes for all of us…

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