Supreme Court's Ruling on Health Care
Reform
At issue is the requirement that most Americans carry health
insurance or face a tax penalty.
The U.S. Supreme Court
could decide as soon as Monday the fate of the most consequential piece of
health legislation since the enactment of Medicare and Medicaid nearly a
half-century ago.
The court is expected to
hand down its ruling on the constitutionality of the Patient Protection and
Affordable Care Act, the Obama administration's signature legislative
achievement.
The law set in motion a
series of reforms designed to extend health coverage to more than 30 million uninsured
Americans. It seeks to accomplish these goals in several ways. More
lower-income people will be allowed to enroll in Medicaid, while other
uninsured individuals can buy coverage through new state health insurance
exchanges. Some people who buy coverage may qualify for tax credits.
The 2010 law's most
controversial component -- and one of the key targets of the Supreme Court's
scrutiny -- requires almost all Americans to maintain health insurance coverage
or pay a penalty.
The law also aims to improve
the quality and efficiency of health care. For example, there are programs to
improve care coordination and reduce fraud and abuse in Medicare, the
government-run insurance program for older and disabled Americans.
A number of the law's most
popular provisions are already in effect. For instance, parents in private
insurance plans that offer dependent coverage can keep their adult children on
the plan up to age 26. And most plans must cover preventive health screenings,
such as mammograms and colonoscopies, at no out-of-pocket cost to the patient.
Core elements of the law --
such as expanding Medicaid, establishing the state health insurance exchanges
and requiring people to have coverage or pay a penalty, known as the
"individual mandate" -- aren't scheduled to take effect until 2014.
The high court could decide
to uphold the law in its entirety, strike it down entirely, strip away key
provisions, or delay a decision until after penalties for not having insurance
are assessed. No matter how it rules, there's no sign that the torrid debate
over the cost and delivery of health care in the United States will be put to
rest.
A recent Harris
Interactive/HealthDay poll found, for example, that most Americans agree
that changes are needed to sustain Medicare, but few want to pay higher taxes
or spend more out of their own wallets to prop up the financially ailing
program.
"I think it's a safe
bet that the health-care cost debate is going to persist," said Ilya
Somin, an associate professor at George Mason University School of Law in
Arlington, Va., who has written legal briefs challenging the individual
mandate.
The crux of the court
challenge
One of the key questions
that the Supreme Court is being asked to address is whether the individual
mandate is constitutional. Opponents of the provision, set to take effect in
2014, argue that Congress cannot force people to buy health insurance or tax
them for failing to pay the penalty.
Another point of contention
is whether the law can survive without the individual mandate. New protections
in the Affordable Care Act ban insurers from denying anyone coverage because of
pre-existing medical conditions or from inflating premiums based on a person's
medical history. But the law's architects insist that it would be too costly to
implement these reforms if only the sick bought insurance.
"Without that
requirement, there's an incentive for people to wait and purchase coverage only
after they need medical service," said Robert Zirkelbach, a spokesman for
America's Health Insurance Plans, a Washington, D.C.-based trade association
representing the health insurance industry.
Also at issue is the
constitutionality of the law's Medicaid expansion. States, in exchange for
additional federal funding, must cover nearly all non-Medicare-eligible adults
at or below 133 percent of the federal poverty level. In 2012, the cutoffs are
$14,856 for an individual and $30,657 for a family of four.
In the two years since its
passage, the Affordable Care Act has been the target of multiple lawsuits, with
a handful of cases working their way through the federal appellate court
system.
In previous cases, the 6th
Circuit Court of Appeals in Cincinnati and the D.C. Circuit Court of Appeals in
Washington upheld the individual mandate. But the courts have not ruled in
lockstep. The 11th Circuit in Atlanta found the mandate unconstitutional but
allowed the rest of the law, including the Medicaid expansion, to stand.
Last November, the U.S.
Supreme Court agreed to hear arguments from two 11th Circuit cases filed by the
National Federation of Independent Business and a 26-state coalition led by the
State of Florida.
In March, the high court
heard oral arguments on the Medicaid expansion and the individual mandate as
well as the mandate's severability from the rest of the law. It also considered
whether the fine for not buying insurance is a "penalty" or a
"tax." That distinction is important because federal law bars the
court from ruling on a tax dispute before the tax is levied.
Predicting the outcome
Constitutional law experts
who followed proceedings in the case believe that Justice Anthony Kennedy, a
moderate Reagan-era appointee, may hold the deciding vote. On Day 2 of oral
arguments in March, Kennedy said the federal government has "a heavy burden"
to justify Congress' right to mandate health insurance coverage. Yet he also
seemed to acknowledge the government's view that health insurance is different
from other markets. Chief Justice John Roberts, another Republican appointee,
also posed questions that seemed to both bolster and undercut the government's
position.
"I think that there's
a strong possibility that the court will uphold the entire law, 6 to 3, with
Kennedy and Roberts voting to uphold it," said law professor Renée
Landers, director of Suffolk University Law School's Health and Biomedical Law
Concentration, in Boston.
She found both justices'
questions "quite balanced" and believes "both of them have this
institutional concern for the court about wiping out in one fell swoop 70-plus
years of jurisprudence on the Commerce Clause," the section of the
Constitution that gives Congress the power to regulate activities that affect
interstate commerce.
"If the law is
invalidated in any respect, it'll be a 5-4 decision, clearly along Republican-appointee,
Democratic-appointee lines," Landers added.
At Intrade, an online
financial exchange for wagering on political, entertainment and financial
events, investors have been predicting the individual mandate has a better than
57 percent chance of being ruled unconstitutional by the court before year's
end, and a 61 percent chance of its demise before the end of 2013.
George Mason's Somin
doesn't believe the federal government's arguments in defense of the mandate
stand up to scrutiny. "When you look at each one of them closely, they all
break down against inspection," he said.
What it means for patient
care
Striking down the health
reform law would end health insurance coverage for millions of Americans,
disrupt efforts to improve care coordination and halt important insurance
market reforms, among other reforms, according to the American Medical
Association.
"We continue to
support the health reform law as an important step in transforming our
health-care system, although we are working hard to improve and make important
changes in the law," AMA President-elect Dr. Jeremy Lazarus said in a
prepared statement.
Added Michael Miller,
policy director at Boston-based Community Catalyst, a national consumer
advocacy group: "The implications for patients . . . and for the
health-care system are catastrophic."
Miller cited a Robert Wood
Johnson Foundation-funded study published in the journal Medical Care
that suggested that high rates of "uninsurance" in a community have a
"spillover effect," negatively influencing working-age adults' and
seniors' access to health-care services and satisfaction with the care they
receive.
A majority of working-age
adults and children in America -- 53.5 percent in 2010, according to a study by
the National Institute for Health Care Reform -- have coverage through an
employer-sponsored health plan.
Tracy Watts, a senior
consultant in the Washington, D.C., office of the consulting firm Mercer LLC,
said people in employer-sponsored plans can expect to see continuing efforts to
replace traditional coverage with so-called consumer-directed plans, which pair
a high-deductible plan with some type of savings account. There will also be
greater use of incentives for individuals to stay healthy and manage chronic
conditions, and higher out-of-pocket costs, she said.
"With or without
reform, employers are focused on how to manage costs," Watts said.
"ObamaCare"
opponents, however, suggest that the public would be better off if the Supreme
Court were to invalidate the entire law.
"One of the criticisms
that has been leveled at people who say this [law] should go down is, 'Well, we
don't want to go back to the way it was,' and we agree 100 percent that the way
it was prior to the passage of this law was not working," said Dr. Richard
Armstrong, a general surgeon in Newberry, Mich., and chief operating officer of
Docs4PatientCare, whose members oppose the Affordable Care Act.
Instead, the organization
backs a series of free-market reforms that would put health-care spending
decisions back in consumers' hands.
"The bottom line in
this is that we need to get back to some fiscal sanity in America," Armstrong
said.
More information
(SOURCES: Ilya Somin, J.D.,
associate professor, George Mason University School of Law, Arlington, Va.;
Robert Zirkelbach, spokesman, America's Health Insurance Plans, Washington,
D.C.; Renée M. Landers, J.D., professor and director, Health and Biomedical Law
Concentration, Suffolk University Law School, Boston; Jeremy Lazarus, M.D.,
president-elect, American Medical Association, Chicago; Michael Miller, policy
director, Community Catalyst, Boston; Tracy Watts, senior consultant, Mercer
LLC, Washington, D.C.; Richard Armstrong, M.D., general surgeon, Newberry,
Mich., and chief operating officer, Docs4PatientCare, Atlanta; The Henry J.
Kaiser Family Foundation, Frequently Asked Questions and A Guide to the
Supreme Court's Review of the 2010 Health Care Reform Law, January 2012;
U.S. Centers for Medicare and Medicaid Services, Baltimore; Intrade, Dublin,
Ireland; September 2011, Medical Care
No comments:
Post a Comment