By upholding the Affordable Care Act (aka “Obamacare”), the Supreme Court set aside the greatest single existential threat to the law: a finding that some or all of the law is unconstitutional. A ruling against it could have delayed achievement of the goal of providing near-universal health insurance coverage for at least another generation. More immediately, it would have introduced chaos into the system, as I blogged about (and CNN reported on today with a link to a KevinMD retweet of my post) back in April. A mixed verdict—overturning the health insurance mandate but keeping most of the rest of it—would have raised a whole host of practical concerns, including whether the subsidies, exchanges and insurance market rules survive with it.
As it was, the Supreme Court upheld the individual insurance requirement—defined as a “tax” in the majority opinion written by Chief Justice Roberts. Check out the SCOTUS blog for an excellent PLAIN ENGLISH explanation of the individual insurance ruling.
On Medicaid, though, the court upheld the part of the law that expands Medicaid to cover people up to 133 percent of the Federal Poverty Level—but removed the main penalty available for the federal government if a state doesn’t comply, which would have been a cutoff of all existing federal Medicaid dollars to non-compliant states. Instead, it leaves the “carrot” (more federal dollars for Medicaid: 100 percent initially, declining to 90 percent) but not the “stick” of a complete loss of Medicaid funds. This leaves the door open that some states will decline to expand their Medicaid programs to all of the poor and near-poor as the ACA intended.
Overall, though, the decision gives a green light to the ACA, meaning that the federal and state governments have no constitutional or legal reason to further delay implementation of the health insurance subsidies, insurance market reforms, individual insurance subsidies, essential benefits packages, delivery system reforms, or Medicare benefit improvements—that is, just about everything in the law.
As a result, the Supreme Court decision should result in tens of millions fewer uninsured persons in 2014, some 16 million through subsidized private health insurance, and up to another 17 million on Medicaid, depending on how many states go along with the Medicaid expansion. ACP, a long-time champion of universal health insurance coverage, said in a statement released today that the Supreme Court decision is a “victory for improving health care for all Americans.”
The law continues to face formidable challenges, however. Republicans insist that they will do everything in their power to repeal it, or at least to try to deny needed funding so as to slow down or impede its implementation. They won’t get too far, because the Senate and White House won’t go along. But the 2012 elections could change all of that.
It remains to be seen if the states—especially the 26 that brought the unsuccessful constitutional challenge to the Supreme Court—will continue to resist setting up the heath exchanges and preparing for more Medicaid patients, perhaps until after the 2012 elections, even though delay could put them in the precarious position of inviting the federal government to run their exchange if they haven’t made enough progress on their own by early next year. Governor Bob McDonnell of Virginia, chair of the Republican Governors Association, told NBC news that states are “stuck” with the law “at least until we see if we have a new Senate and a new president.”
Finally, the biggest challenge is that President Obama, congressional Democrats, and organizations that support the ACA have not yet persuaded a solid majority of the public on its merits. While large majorities favor many of the law’s specific improvements, “Fewer than half of Americans have supported the law in every major poll since its passage. A significant portion of this opposition comes from those who say the law did not go far enough,” according to a Washington Post article. The individual insurance requirement is supported by less than a third of the public.
Still, despite the challenges, today is a day to celebrate the fact that Supreme Court ruled in a way that will allow most of the law to go forward, moving us closer to the goalpost of universal health insurance access for all and better consumer protections and benefits for everyone.
Today’s question: What is your reaction to the Supreme Court decision? What do you think it means for the future of the ACA?