Cited as the "most important debate of our time" and the hottest ticket in Washignton DC this week the healthcare debate kicked off a record setting 6 hours of arguments over a period of three days. You can listen to proceedings here. You can download Monday (pdf transcript), Tuesday (pdf transcript) and Wednesday Part 1 (pdf) and Part 2 (pdf).
The government counters that everyone consumes health care and that the only question is when. without the requirement to have health insurance the people who get healthcare without insurance are forcing everyone else to pay for it predominantly in the form of cross subsidization in the pricing
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Tomorrow I will have the pleasure of talking with Dr Sam Bierstock, MD BSEE on Healthcare RadioNow in what will be my regular radio podcast spot for Voice of the Doctor 2:30pm ET. We will be discussing our initial thoughts on the proceedings and the potential impact this will have on healthcare and in particular clinicians. It should prove to be a lively debate as Sam and I have opposing views. We will be discussing the Affordable Care Act (ACA) (full text in pdf form) and in particular the Supreme court debate that centered on four questions
1) Threshold Question (Monday)
The justices must decide whether an 1867 law called the Tax Anti-Injunction Act prevents the court from even considering this bill right now. (A provision dating back to 1867 to prevent every man and his dog from challenging and holding up any taxation by challenging it as unconstitutional, refusing to pay it till the courts make a hearing and tying up the government in court rulings and bankrupting them in the process.
Under the regulation there are no penalties until 2015 so the argument is that there is no case because nobody has paid the penalty or suffered any financial injury yet.
The debate was lively and provided much fodder for various interpretations and views of possible outcomes. It seems unwise to attempt to divine the tea leaves - what does seem to be generally agreed is that healthcare has to change. On its current trajectory with the aging "baby boomers" who will get sicker and require more care and a current cost per head of population far higher than any other developed country, healthcare is on life support and not doing well.
2) Individual Mandate
The regulation requires everyone to have health insurance. Challengers assert that this is the first time the federal government
Central to this requirement is the need to spread risk to allow for the other provisions in the regulations that mandate affordable coverage for everyone with no discrimination based on previous medical conditions, and a requirement to charge people in the same age groups the same rates.
The government counters that everyone consumes health care and that the only question is when. without the requirement to have health insurance the people who get healthcare without insurance are forcing everyone else to pay for it predominantly in the form of cross subsidization in the pricing
No matter who pays for healthcare there is an increasing focus on value based purchasing. In fact e-patient Dave blogged on his most recent attempts to be a responsible engaged patient and his frustrations at the lack of transparency in fees, bills and the ultimate cost of the care and tests we receive.
3) Striking down all other provisions
Is the mandate is truck down should this apply to all components and if not do some remain while others are struck down. Much of this is tied up with the concept fo shared risk. If there is no requirement for everyone to have health insurance then only those that are sick will buy healthcare coverage making the health insurance unaffordable and uneconomic
In this point there is mostly agreement - the government agreeing that the insurance companies could not sustain a business model with out the shared risk and the opponents arguing that all components are so inextricably intertwined that everything would have to be invalidated.
It does seem that without putting *everyone* in the pool the other principles of extended coverage are unfunded and likely non-starters. The underlying question seemed to be could the Supreme court carve this bill up or was this really a job for congress. Given the 2700 pages and the push back from the justices of going through this item by item if the individual mandate falls so goes the rest of the elements.
4) Is the Expansion of Medicaid Unconstitutional
Is coercing the states into participating in the program where the states share 50% of the costs for the poor and disabled. States have the option of opting out (none have done so to date). As set out in the regulations the costs of the big expansion of coverage are covered by the federal government for 3 years but this shifts to the states over the following years rising to 10% by 2020. The opt out is an all or nothing proposition - they can't opt out of just the expansion, and must either opt out of the whole program or take it plus the expansion and increased costs
My simple take on this - the states are happy to take the hand outs and have become increasingly dependent on federal funds but balk at the idea they might be required to extend the coverage.... or as one justice put it
"It’s just a boatload of federal money for you to take and spend on poor people’s health care"
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