Question

From the Affordable Care Act and Payment Reform, What is the Supreme Court and it's decision on the constitutionality of the law. What do you think the outcome will be in the future and why? please write a reflection no fewer than 200 words.

Answer 1

In March 2010, President Obama signed into law the Patient Prrotection and Affordable Care Act (the Act or ACA), which is felt to be the most comprehensive reform to health care in the United States since the enactment of Medicare/Medicaid in 1965

Nothing this big happens overnight and without controversy. Numerous concerns were raised from all demographics and from both sides of the political aisle. Some of the concerns were legal questions regarding constitutionality and so legal processes began to address this issue. In June 2012, the Supreme Court decided in a 5–4 vote that the Act is constitutional. This has allowed the legislation to stand and over the next few years the more transforming parts will start to be implemented. It is important to understand the issues surrounding the Supreme Court decision and the impact this may have on health care and specifically the practice of neurology.

The Patient Protection and Affordable Care Act (ACA or the Act) is considered the most important legislation passed by the US Congress since the creation of Medicare and Medicaid in 1965. It is the direct result of rising health care costs in the United States and was a major initiative of President Obama's first term. During its passage there was much debate surrounding the legislation. While some of this debate continues today, on June 28, 2012, the Supreme Court of the United States (SCOTUS) put many of the legal questions to rest and paved the way for implementation of the Act. This article will review the issue before the Supreme Court and then discuss some of the areas that are likely to impact on neurology practices and patients.

The most important legal question about the Act before the Supreme Court was on the constitutionality of mandating all Americans to purchase health insurance or pay a penalty. If this section was determined to be unconstitutional, then the other legal questions would need to be addressed. The Act states that if a person cannot show proof of insurance, the Internal Revenue Service (IRS) will impose a tax on them. Some felt it was unconstitutional, and beyond the scope of Congressional power, to require Americans to buy a private market commodity. The Court decided that because the penalty was treated as a “tax” and Congress has a right to impose taxes, the Act was constitutional. Once this decision was made, it negated most of the other legal questions that were being raised, with one exception; federal funding of Medicaid.1

The Supreme Court was also asked to address an issue related to the expansion of Medicaid. The Act provided for expanding Medicaid eligibility to 133% of poverty level and provided federal funding to states for this expansion. It directed that states that did not expand eligibility would lose all of their Medicaid funding. The Court decided in a 7–2 vote that states could not be coerced to expand their Medicaid offerings; therefore, if a state chooses not to expand its Medicaid program, the federal government cannot withdraw all Medicaid funding to that state. However, the Court did find that if a state chooses to expand coverage, they must accept all of the federal regulations attached to that expansion. They cannot pick and choose where they expand.

What does the future hold?

While the bulk of the ACA tends to focus on insurance reform and not really health care reform, there are sections that attempt to change the way health care is provided. The Act provides for pilot programs and incentives to develop new models of care including Accountable Care Organizations (ACO) and Patient Centered Medical Homes (PCMH). Some organizations have been officially identified on the Center for Medicare and Medicaid Services (CMS) Web site as ACO11 and have agreed to the reporting and payment requirements associated with this designation. They have also agreed to take on a certain amount of financial risk if they do not meet targets. Initially any money saved on care is shared by the insurers and the providers. However, if costs are not lowered, the groups will be penalized and lose money.12 Physician groups are also getting involved with the PCMH or networks of care models. These focus on disease states and organize a patient's care around teams and what the specific needs of the patient may be. Many of these groups are collaborating with insurance companies and are focusing on using electronic resources, guidelines, and registries to improve care and lower costs. PCMH models are trying to engage patients in their health care decisions.13 With both of these models, there are plans for greater public reporting of cost and outcomes. Those groups, hospitals, or physicians providing the lowest cost for care with the best outcomes will be designated by some preferred ranking and patients will be encouraged to use these providers.

The goal for most new models of care is to eliminate the current fee-for-service payment programs and replace them with cheaper, more effective ways of providing care. However, these new models have not been proven to reduce cost or provide better care or outcomes.14 Most of the new models focus on incentivizing primary care providers, defined as internal medicine, pediatrics, and family practice, but not specialists. Specialty groups argue that for certain diseases such as multiple sclerosis, dementia, congestive heart failure, or diabetes, a specialist may be functioning as the patient's primary (main) provider and therefore should be eligible for these incentives. At this time, it remains unclear how specialists will fit in to these new models.

It also is not clear that any of these changes will improve the health of Americans. The talk is all about improving quality and there are programs focusing on reporting of measures related to this. Whether focusing on these measures actually makes people healthier remains to be seen. Clearly change is here and change is always difficult. Now that the Act has been found to be constitutional by the Supreme Court, the health care industry is moving forward with the implementation. Time will tell if we are building a system that is more cost effective and provides better quality and healthier outcomes for our patients.