Updated 12:04 PM: Baker just shared some additional thoughts, specifically addressing what the ruling means for coverage and spending under the Affordable Care Act:
Assuming the ACA ends up implemented as approved by the Supreme Court, there will be substantial new opportunities to obtain coverage for many people who now lack it. But there are some groups to which we should pay new attention.
One is the group of very low income people not now covered by Medicaid. Some states do not now cover everyone under 100% of the federal poverty level under their Medicaid programs. The law had required coverage for this group, but the Supreme Court ruling makes this expansion optional. Some states will choose to expand coverage, but others may not and if they don't then people in this very low income group may need some additional assistance to do something like obtain private coverage through the exchange. It is not immediately clear how many people this may be, nor is it clear what kind of fix is possible in a bitter political environment, but this is a new issue that will need resolving.
Updated 10:17 AM: Health economist Laurence Baker, PhD, chief of health services research, now weighs in:
This is a ruling Republicans and Democrats could come to appreciate. Politics aside, upholding the individual mandate and the insurance reforms associated with it positions the U.S. health-care system for advances centered around individual choice and market-based solutions. Working within the structures of reformed market mechanisms offers a path to improvement in our health-care system that emphasizes the individual choices Americans have cherished, while emphasizing individual responsibility. Restricting the Medicaid expansion further emphasizes this.
In the history of health reforms across countries, including the U.S. Medicare program, it is common to find reforms that generate vigorous debate at the time they are passed, but come to be valued by the population. There is every reason to believe this could be the same. It moves our system in a positive direction, and that will take some significant efforts, but it does so with what are in the grand scheme of things reasonable and measured changes.
We can't stay where we are - our system is frayed at the edges and ripping at the seams. We need to make changes. The changes that have emerged from the Supreme Court today move us in a useful direction that can, after the political to do settles out, be something the country will see as a reasonable and valuable improvement.
The court's decision sustains legislation intended to make health insurance more affordable for non-affluent Americans.
Since the growing unaffordabiity of health insurance is caused mainly by annual increases of the price of health care services and the inflow of new drugs and other valuable biomedical technologies, much more remains to be done by all health care stakeholders and legislators of all stripes.
At the top of our national health-care "to do list" is better harmonizing public and private health insurers efforts to make excellence in clinical quality and low total cost of care a "stay-in-business" imperative for our health industry. Today's Supreme Court decision to uphold 99% of the Affordable Care Act advances this imperative.
Updated 8:57 AM: Philip Pizzo, MD, dean of Stanford's medical school, has provided his thoughts on the Supreme Court's decision:
The Supreme Court ruling requiring individuals to have medical insurance provides assurance that over 35 million Americans will have health-care coverage. The ruling also sustains the requirement that children be covered on their parent's health insurance until they reach 26 years of age; that insurance companies cannot deny health insurance because of pre-existing conditions; and that insurance companies cannot invoke life-time caps on medical care - an issue of particular importance to the millions of Americans with chronic medical conditions.
While there is no denying that the Affordable Care Act that became law in March 2010, and that remains the law of the land today because of the Supreme Court decision today, has many imperfections and problems, it does represent the first comprehensive reform of U.S. health care in our nation's history. It constitutes a beginning and not an end to the our nation's efforts to make healthcare more accessible and affordable. Now with the Supreme Court decision we must move forward to further improve the quality, effectiveness and costs of medical care in the United States. As the costs of health care in the United States have continued to rise, now at nearly 18% of the GDP, our attention and efforts as citizens and as providers of health care need to focus on improving health of our communities by developing more effective health-delivery systems that offer a true value benefit.
Today's decision by the Supreme Court mandates that we move forward, as communities, states and as a nation, to value the health and wellbeing of our citizens with the same pride that we value the personal freedom and dignity we have as citizens of the United States of America.
Updated 8:31 AM: Stanford health economist Jay Bhattacharya, MD, PhD, now shares his thoughts on the ruling, saying it has at least two important implications for health policy:
First, the ruling empowers state governments to take an active role in delaying or preventing implementation of the key provisions of the law. In particular, states now have the power to turn down additional Medicaid funding provided by the law and not risk losing existing Medicaid funds. Cash-strapped states will almost certainly consider this option since they will ultimately be on the hook for financing at least a portion of this expansion. Medicaid is supposed to cover 20 million of the 35 million people who will gain insurance under the Affordable Care Act. If enough states decide to deny the Medicaid expansion, this may substantially reduce the ability of ACA to expand insurance coverage.
Second, the court has ruled that the ACA can impose a tax on people who opt to not buy insurance, as opposed to requiring people to buy it. From a policy point of view, this is important because without the mandate (well, tax, I guess), the state health insurance exchanges have no chance of working. Without the mandate, it would have been possible for healthy people to not buy insurance until they became ill. Financing health insurance for the 15 million people who will gain insurance through the exchanges depends on more or less forcing relatively young and healthy to pay for the relatively older and unhealthy. The law, as envisioned, thus requires a large-scale redistribution of money through this mechanism. There's still an open question of whether the penalty for not signing up for insurance is large enough to deter people from waiting until they are sick to sign up for insurance.
Overall, the ruling will make the implementation of the ACA a bit more difficult. While the federal government's role in health policy remains undiminished, the ruling places more power in the hands of the states.
8:08 AM: Lucile Packard Children’s Hospital pediatrician Lisa Chamberlain, MD, who directs Stanford's pediatric advocacy program, has weighed in on the Supreme Court's historic decision on health care. Chamberlain told my colleague this morning:
This is great news for kids’ health. There will be no more preexisting condition exclusions for kids born with health problems. All kids will be covered as dependents until age 26, and there will be increased access to care for kids on Medicaid.
Previously: Supreme Court mostly upholds Affordable Care Act
Photo by Steve Fisch