Today’s Supreme Court ruling on the Patient Protection and Affordable Care Act of 2010 advances the broad effort to extend health-care coverage and control medical costs, though it raises questions about how certain provisions of the policy will be implemented, Stanford University School of Medicine experts said. Here are some initial comments on the court’s landmark decision.
-Jay Bhattacharya, MD, PhD, associate professor of medicine and a member of the Stanford Center for Health Policy/Center for Primary Care and Outcomes Research:
“Barring legislative action to amend it, the law will be enacted over the coming years, though perhaps not exactly as envisioned. Despite the positive ruling, today's ruling 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 ACA. 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, 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.”
Bhattacharya is a health economist, who has a specific interest in vulnerable populations, the decisions they face that affect their health status and the effects of government policies and programs designed to benefit them.
-Laurence Baker, PhD, professor of health policy and research, chief of health services research and a fellow at the Stanford Center for Health Policy/Center for Primary Care and Outcomes Research:
“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.”
Baker is an economist interested in the organization and economic performance of the U.S. health-care system. Among his research interests are the effects of managed care on the health-care system; the effects of regulation on health-care markets; and the determinants and effects of technological change in medicine.
-Philip Pizzo, MD, dean of the School of Medicine:
“While there is no denying that the Affordable Care Act that became law in March 2010 — and that remains the law of the land 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 our nation's efforts to make health care 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 percent 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.”
Pizzo is an advocate of major health-care reform (as well as changes in health-care delivery) to improve quality and efficiency and reduce costs. He participated in discussions leading to the approval of the act, including a White House meeting on health-care reform, and meetings of the Council of the Institute of Medicine and the board of directors (which he chaired) of the Association of Academic Health Centers. Pizzo has been an advocate of a single-payer system. He is a leading specialist in childhood cancer and HIV.
-Lisa Chamberlain, MD, MPH, assistant professor of pediatrics and medical director of the Pediatric Advocacy Program at Stanford School of Medicine and Lucile Packard Children's Hospital:
“This is great news for kids’ health today. 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.”
Chamberlain has been actively involved at both the federal and state level in advocating for children’s health.
-Arnold Milstein, MD, professor of medicine and director of the Clinical Excellence Research Center at Stanford:
“The court's decision sustains legislation intended to make health insurance more affordable for non-affluent Americans.
“Since the growing unaffordability of health insurance is caused mainly by annual increases in 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 of 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 percent of the Affordable Care Act advances this imperative.”
Milstein is a nationally recognized innovator in health-care policy and delivery. He helped to draft portions of the legislation. His focus is on testing new health-care delivery models that lower costs and improve clinical outcomes.
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