On June 25, 2015, the Supreme Court again upheld the ACA against a challenge, this time to federal subsidies. Was this a good or bad decision? What grade should we give the court, and for that matter congress as well?
Because the court held that the congressional intent was to provide insurance for more people, the decision was good. It preserves affordable insurance for financially challenged individuals, and many of my patients have insurance today but were uninsured before the ACA. Fewer people are uninsured now, thanks to the ACA. Who could possibly be against getting more patients health insurance, someway, somehow?
However, the costs of this insurance to those without subsidies have escalated, sometimes un-affordably and sometimes resulting in job loss rather than job creation. But it now remains for congress and states to continue to develop improved methods paying for health care, including less expensive health care delivery systems and more optimal utilization of resources so that premiums can be reduced. Such value-based programs are being developed by organized medicine (Choosing Wisely) and by the administration as well (Accountable Care Organization expansion, and the Oncology Care Model of Medicare).
Had the court decided to strictly interpret the language of the act and prohibited subsidies for those individuals on the federal exchange, many patients nationally would no longer have been able to afford insurance, and their care would have been threatened or interrupted. Many of my cancer patients would have had to discontinue life saving therapy. If this had happened to any of your relatives or friends, you would have been outraged.
So it is report card time, and here are my grades.
For the Supreme Court:
Sustainability of health care: B, since the insurance market is stable, but costs are continuing to rise and for many people their premiums are too expensive and their higher deductibles reduce their desire to get treatments.
Sustainability of laws: D, since the Supreme Court has now taken the view that they can correctly interpret the intent of any law and change the language written by Congress, thus leading to a lack of confidence that any law will continue to work like Congress said it would.
Overall: the Supremes get a B
What about Congress:
The grade for drafting clear legislation: D, since there was ambiguity between intent and language.
Grade for health care reform: C, since access is better but costs are higher than anticipated, and implementation has been inefficient and across the states inconsistent
Grade for finishing health care reform: Incomplete, since programs to increase outcomes and reduce costs (a net increase in Value) are just now being more widely implemented.
Overall Congress earns a C- and a note from the "professors" (the public) to work harder and do better. I know they can.
Health care reform is not yet finished, and it will not be in our lifetimes. In my estimation, every health care system throughout the world has problems. Today, we are living in America where the reforms in health care delivery and scientific advances continue to give more of us confidence in long lives and happiness with control and prevention of illness. For tips on how to navigate the reforms in health care, see my book Surviving American Medicine. And be sure to discuss the impact of theses reforms on your own doctor's practice at your next visit.