Imagine you’re a physician, and you have a full schedule of patients to see the day after the Supreme Court has thrown out the entire Affordable Care Act. Imagine you never liked “Obamacare” in the first place, so you are feeling pretty good about the Supreme Court decision.
Your first patient, an elderly retiree named Mrs. Jones, comes in for her annual Medicare wellness visit—one of the new Medicare preventive benefits offered at no cost to the patient. But this new preventive service benefit was created by the ACA, so presumably with the ACA overturned, Medicare no longer is allowed to pay for wellness visits. Do you tell Mrs. Jones that Medicare might not cover the visit? Provide the visit anyway, hoping that somehow Medicare will find a way around the Supreme Court ruling and pay for it? Offer it at no charge, or try to collect the 20% you would collect for a normal (non-preventive) office visit?
Your second patient, Mr. Jones, another senior, comes in for a follow-up visit for an ongoing chronic condition. You decide to renew his expensive brand-name prescription drug, knowing that he is eligible for a 50% discount because he has fallen into the Medicare Part D “doughnut hole.” Oh wait ... the Medicare Part D drug discount was part of the now-defunct ACA. So does that mean he now has to pay full price? Do you prescribe the drug anyway, knowing he can’t afford to pay the regular retail price? Prescribe a lower cost no-name brand drug that he doesn’t tolerate as well?
Your billing person prepares to submit the claim for Mr. Jones’ office visit. It ordinarily would have been eligible for the 10% bonus that Medicare pays for all office visits, nursing home and custodial care visits provided by primary care physicians. But that was before the Supreme Court overturned the ACA, and with it, wiped out the primary care bonus created by the law. With the bonus gone, your practice will lose about $4,000 over the next six months. Does the bonus disappear immediately—with this visit? What happens to bonus payments that were already paid out? Who knows?
Next up is Ms. Wilkins, a single mother of three who is seeing you for her diabetes and congestive heart failure. She is fortunate enough to be among the 50,000 Americans enrolled in the low-cost Pre-existing Condition Insurance Plan created by the Affordable Care Act and administered by the state. Oh wait, that was until the Supreme Court decision. With the ACA gone, the authority and funding for the Pre-existing Condition Insurance Plan disappears. Will she still be covered for this visit and any tests or medications she needs? And if so, for how long before the program is forced to shut down? Where else will she find affordable insurance? Will she go without it? Who knows?
A text message comes into you from your 22 year old son, a recent college graduate who hasn’t found a job. He has a doctor’s appointment for the knee he hurt playing rugby, and wants to know if he still will be covered by your health insurance plan. But the requirement that young adults up to age 26 be covered by their parents’ plans was part of the ACA, so presumably, your health plan no longer is obligated to keep him. Will it drop him? If it keeps him on, for how long, and for what extra premium?
You start thinking about your oldest daughter, a fourth year medical student who plans to apply for a loan repayment program from the National Health Services Corps in exchange for providing primary care in an underserved community. But the funding for NHSC in 2012 comes entirely from dollars mandated by the ACA. Will the NHSC now have to cut back on its award amounts and recipients? When, and by how much? Will she no longer be able to get a NHSC slot?
Your practice has joined with other primary care physicians in the community to become an accountable care organization (ACO) under the Medicare Shared Savings Program. It has spent tens of thousands of dollars and countless hours to do the planning and set up the infrastructure to qualify. But the federal money to pay for the Shared Savings Program comes from funds obligated by the ACA, so with the ACA gone, the ACO program may be suspended as well. Does that mean your practice wasted all of that money preparing to become an ACO?
Your local medical school has applied for Title VII primary care grants for faculty and scholarships for low-income students—the only federal program specifically designated to support primary care training. But the Title VII grant program was part of the ACA. Does that mean that the grants will be suspended? Who knows?
Your hospital expanded its internal medicine residency program because of a provision in the ACA that redistributes unused residency slots in other specialties to primary care. Who will pay for them if Medicare can’t? Will the slots have to be eliminated?
I could write pages and pages more of programs created by the ACA that would be invalidated if the Supreme Court overturns the whole law. What I can’t tell you—what no one can tell you—is how the federal government will deal with the absolute chaos that will follow.
Rules will have to be withdrawn and re-written, contracts suspended, agencies closed down or downsized, agreements renegotiated, delivery reform pilots terminated or scaled back, and mandated insurance protections suspended—with little guidance from the Supreme Court or Congress on what to do next. And there’s almost no chance that Congress will step in to repair the wreckage.
In the meantime, physicians and patients will be left reeling by the resulting chaos and confusion created by the court’s decision.
I haven’t even mentioned the 32 million Americans who would have gotten coverage in 2014 if the law was sustained—but will lose the most if the court overturns it.
Henry Aaron, a renowned health care expert at the Brookings Institution, also predicts chaos if the Supreme Court overrules the law:
“And what if the Supreme Court throws out the whole bill?
That would leave America, including the nearly 50 million uninsured, even worse off than we were four years ago: with higher costs, more uninsured and a political atmosphere poisoned by the failure of an all-out effort to reform a health care system everyone knows is flawed.
Health insurance costs, driven by the steady march of new technology and population aging, will claim ever larger shares of our income. Those higher costs will make health insurance unaffordable for more and more people.
It would be hard to imagine any President or Congress returning for a generation to touch the endless political grief of basic health care reform with a ten-foot pole.
Is that the future we want?”
Today’s questions: What are you going to do to prepare for the chaos that will happen if the Supreme Court overturns the entire Affordable Care Act? Is that the future we want?