Tom Roberts Commentary: “Supreme Court Upholds the Affordable Care Act”

It would be hard to overstate the importance of the Supreme Court ruling yesterday, supporting the constitutionality of the Affordable Care Act. Commonly known as Obamacare by its detractors, this complex piece of legislation aims to do nothing less than transform the provision of health care in our country. The somewhat surprising ruling written by Chief Justice John Roberts assures his place in the history books of our country. Instead of supporting the ability of Congress to mandate the purchase of health insurance, Justice Roberts did affirm the ability to impose a tax on people who chose not to purchase health insurance. With this component of the Affordable Care Act in place, essentially the entire law is left intact.
The only piece left in question will be the potential expansion of Medicaid services. States will now have the option of deciding whether or not to take additional Federal money in order to expand Medicaid coverage. Rather than all or nothing, states can decide to receive the same level of Medicaid support as they are currently. Or a state can chose to expand that level of federal support in order to provide health care coverage for all citizens with incomes below 133% of the federal poverty level. We can only hope that what our own state legislators decide is based on real needs and not on partisan politics.
While the political process has dominated recent news, it’s important to remember that the real issues here are not political. We have a health care system which is badly in need of improvement. Too many people are either uninsured or underinsured; mostly because they can’t afford health insurance, not because they don’t want it. Our personal, business, state and national budgets are unsustainable unless and until we make major changes in how we finance and receive health care.
Many people believe that the Affordable Care Act did not go far enough. For them, what we really need is a single payer system similar to Medicare, for everyone. At the other end of the spectrum, some people apparently feel that medical care is optional and should be dependent on one’s ability to pay. Now, fortunately for all of us, the Affordable Care Act means that we can approach problems in our health system from somewhere in the middle. Most people will pay at least something in order to receive health insurance. For those who really can’t afford it, we have the option of expanding Medicaid. As a society we certainly have the resources to make sure that no one is denied medical care because of cost. It’s past time to make this happen.
But access by itself is not enough. At the same time we need to control spending and improve quality. We know this is possible by looking at how health care is supplied in different parts of our country. Spending for treatment of the very same illness may vary as much as 3 or 4 times from one locale to another. The compelling part of this is that the quality of medical care and the outcomes are no better and sometimes are worse in the high spending areas. Spending more does not mean better care. This doesn’t mean that we can simply cut payments to areas with high spending. What it does mean is that we can and should find ways to make high spending areas more efficient. At the same time we need to improve the quality of medical care in all areas.
As those of us working in the medical system know, a single payer program like Medicare does not guarantee good outcomes or efficient medical care. Likewise, having individuals pay for their own medical care does not necessarily lower costs and improve quality. These are complex issues that need careful answers. As much as we would like it, there is not a simple solution, and sound bites won’t help. No single federal law by itself will solve all of these problems. Fortunately we have made a start with the Affordable Care Act. We will begin to address complex issues like supporting primary care based Medical Homes and learning which treatments actually work best. Many people believe we have to migrate away from our current fee for service payment system. This Act supports the creation of health organizations that are accountable for the costs and outcomes of the medical care they provide. Hospital systems need to focus on improving population health, not the bottom line. The best outcomes can often be achieved by using the least expensive approach, not the most expensive. We need to turn our insurance industry into one that pays for needed medical care, not one that makes money by avoiding high risk consumers.
It’s an exciting time. With the constitutional issue now decided, we have opportunities to move forward. We can only hope that our leaders are ready to move ahead with new approaches and that we will not continue to be stuck in partisan politics.

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