28 June 2012
So this is great news and a great day. My quick reactions:
First of all, CNN & FOX. Once again proving that being first is a higher priority than being right. How embarrassing. At least their soon-to-be-fired producers will be able to get health care coverage.
Second, Roberts: I have to give him a little credit. I fully anticipated him to be a partisan hack and invalidate the law. Perhaps the burden of history weighed heavily on him, perhaps the delegitimization of the court influenced him, or perhaps the sheer radicalism of Scalia's dissent drove him to uphold the law. Regardless, he got it right. Make no mistake, though, he did what he could to advance his long-term agenda by slowly restricting the reach of the commerce clause.
While most of the focus centered on the the Heritage-Foundation-developed mandate (aka the greatest threat to liberty ever), it's important to note that the 4 conservatives wanted to invalidate the entire law, and there is far, far more than the mandate in Obamacare. 12 million Americans will get rebates from their insurers this year based on the ACA's insurance regulations. Rescissions of policies is now prohibited. In a couple of years, pre-existing conditions will be covered under the guaranteed issue provisions, and the moribund individual market will be resuscitated by the insurance exchanges. All of these huge reforms survived and will transform healthcare in a good way.
The mandate itself may work, or people may prefer to pay the "tax" penalty and go without insurance. We will see. If enough people opt out and insurers are experiencing serious adverse selection in a few years, perhaps the partisan rhetoric will have died down enough that Congress can tweak the incentives at bit. One can hope, anyway.
The Medicaid ruling was disappointing but not fatal. The gist is this: the ACA expanded eligibility for Medicaid all the way up to 133% of the poverty line. This is significant because in many states, the eligibility thresholds are very stingy, and in some if you're male and without dependents or a disability you are never Medicaid eligible no matter how little you make. So this is a very large expansion of coverage. It is still allowed under this ruling, but no longer can the Feds make it compulsory for the states.
So what does that mean? Not clear. Most states probably will implement the Medicaid expansion, which is for the moment fully funded by the feds. There are concerns that the feds may shift the costs back to the states in a few years, but that's not clear yet. I can see some GOP governors refusing to implement the expansion on these grounds (really just to be recalcitrant dicks; I'm looking at you Scott Walker), but there will be huge pressure on them from their medical community to accept what is essentially free money. If they do refuse, then it's going to leave a large portion of their lower classes without access to health insurance.
For the ER, I predict little will change. ER utilization has been going up nationwide for two decades, and that trend will not change, regardless of the fate of the ACA. When, in five years, ERs are busier and more overcrowded, I predict it will be held that this is a consequence of the "failure of Obamacare" and I'm going to call BS on that in advance unless it is shown that the rate of ER volume growth accelerated after 2014. Which is possible, but I don't think is super likely. Many of the soon-to-be insured are already coming to the ERs as no-pay patients, and the only difference is that we will be reimbursed for those services that we are already providing. Some of them may be diverted to PCPs' offices, though the limited capacity of the primary care network sadly ensures that will be a small number. To the extent that ER volumes do increase, it's a failure on the part of the system to create enough primary care capacity, not the expansion of coverage.
It's worth noting that the ACA does contain a 10% boost to primary care providers' reimbursements. So that may help improve access to primary care, and there are also significant expansions of Community Health Centers.
Cost control is where ACA is weakest, and more will need to be done to bend the curve of health care inflation. Sure, the IPAB may have some effect, if it is ever implemented. Medicare is already putting into place other reforms such as value based purchasing and others. But this is certainly the point where the ACA is only a start. Wether Congress can get it together well enough to add onto it in a productive fashion is to be seen.
The saddest element of this whole kerfuffle is that liberals and policy wonks are celebrating the survival, by the thinnest of margins, of reforms which in the best-case scenarios will leave the US with the worst access to health care and health insurance in the OECD, with the highest cost per capita in the developed world, and with the worst outcomes in the industrialized countries. The passage and survival of the ACA are big wins, but they still leave the US with the worst health care in the world, and one party is hell-bent on dragging us backwards. So I will celebrate the win and spike the football and all that fun stuff, but tomorrow morning we've got to get up and keep working to reform our system further. Because what we have is not good enough.
Posted by shadowfax at 11:05 AM