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Harvard Reviews of Health News

High Court Upholds Affordable Care Act

In a landmark ruling, the U.S. Supreme Court has upheld nearly all of the 2010 health care reform law. The court approved even the law's most disputed part -- a requirement that nearly all Americans have health insurance. Chief Justice John Roberts, a conservative, joined four liberal justices in the 5-4 ruling. They found that the mandate to buy insurance is allowed under the government's taxing powers. The Obama administration also sought approval based on the power to regulate interstate commerce. But the court rejected that argument. The majority did reject one provision of the Affordable Care Act. That section dealt with the expansion of the Medicaid program. This is one major way that the law expands insurance coverage. The court said that the expansion can proceed. But it said the federal government cannot cut off all Medicaid funding for states that do not agree to expand the program. Some parts of the law have already taken effect. For example, family insurance plans now cover children through age 26. In 2014, people will have to have insurance or pay a tax penalty. The Associated Press wrote about the ruling June 28.

What Is the Doctor's Reaction?

The Supreme Court has ruled that the Affordable Care Act can stay. It is constitutional, the judges say in a 5 to 4 vote.

What do the doctors say? I am a doctor, so I can be an example. Like every colleague I have talked to today, I am very happy that the health care reform bill was not struck down. This reform has not been perfect, but it is a good step in the right direction. And we very much need to take steps to change our costly system. Broadly speaking, the health care system has not functioned very well in the last decade.

This act passed into law 2 years ago. The main part of the bill that was controversial was the insurance mandate. People who do not have health insurance through their employer or the government must buy insurance for themselves or pay a penalty. Large businesses are required to provide health insurance for employees or pay a penalty. For lower-income families, the government will help pay for insurance. Because of the Affordable Care Act, at least 30 million more Americans will have insurance coverage by 2019.

This expanded coverage is the most valuable part of the act. Being uninsured is a terrible gamble. I am a primary care doctor. Of all the problems that my patients have, lack of health coverage is the most unmanageable. It is devastating to see what people go through when they don't have insurance.

Here are a couple of examples from my practice.

  • Last year, an uninsured patient with epilepsy told me he was choosing to buy groceries instead of seizure medicine. He knew he would have a grand mal seizure roughly once each month, but he had to make a trade-off.

  • I had several phone calls from a patient who would not come in to the office to see me. She had abdominal pain, and hoped I might be able to diagnose this over the phone and provide a plan. She put off tests because she was not insured. Her pain was from an ulcer. When it was not treated promptly, the ulcer made a hole in her bowel wall. She ended up with emergency surgery, a devastating infection and a wound that required months to heal.

Many different doctor groups have cheered the Supreme Court decision. I am cheering, too.

What Changes Can I Make Now?

With the Affordable Care Act out of the courtroom, we can stop holding our breath and watch for ways to move forward.

For state governments, this means it is time to organize services such as health insurance "exchanges" that are part of this law. Exchanges will help make the terms of insurance policies transparent. They will encourage price competition for plans.

For doctors, there is work to be done. Doctors need to shift toward electronic health records that one center can easily share with another. We need to assemble cost-conscious teams called accountable care organizations (ACOs). These ACOs will coordinate care and help doctors communicate with each other.

For you, the court's decision may signal that it is time to shop for health insurance. Or it may be a reminder that you need to pick out a primary care doctor you can trust.

What Can I Expect Looking to the Future?

The new law has already had some benefits. Young adults can stay on their parents' health plans until age 26. Medicare patients in the "donut hole" of prescription costs are seeing reduced drug charges. There are no more copays for preventive care visits.

Still ahead is the forming of a new government group, the Independent Payment Advisory Board. This committee will look at the way doctors are paid. It will decide whether there are practical ways to change this system. Some doctors are wary about this. They fear that this will lead to lower payments from Medicare. Some Medicare patients are concerned it might reduce the number of doctors who are willing to see patients with Medicare.

But I think this board has great potential to make our system more sensible. It is time we took a fresh look at the way payments shape our health care system. Right now, doctors usually can bill for a service only if they see a patient in the office. The system pays much better for procedures than for preventive care, for time spent in counseling or education, or for a "watch and wait" approach to medical symptoms that might go away on their own. The system doesn't pay for coordinating care by phone. In the age of cell phones and e-mail, this is hardly practical.

The Affordable Care Act is a healthy way to start improving our health care system. I cheer the Supreme Court in its decision to keep it as law.

Author: Mary Pickett, M.D.
Date Last Reviewed: 6/29/2012
Date Last Modified: 6/29/2012