Within the next two weeks, the Supreme Court's long-awaited ruling on the Affordable Care Act (ACA) will be announced. During these long months of speculation leading up to the decision, I've thought about what the range of possible outcomes of the case could mean for New York State's health system. Here's what may happen, and what I see as the key opportunities -- and obstacles -- for New York under each scenario:
- The law is upheld in its entirety. If the entire ACA holds, New York will need to continue to move quickly to prepare for the full implementation of the law by 2014. Fortunately, we are off to a good start: Governor Cuomo authorized the establishment of New York's Exchange, which will serve as the central mechanism for connecting people to insurance coverage options; the State has secured Federal grants to support the development of the Exchange; and new Information Technology solutions are being introduced to update the State's antiquated and disjointed systems of enrollment into public coverage programs. If the law stands, an estimated 1.2 million New Yorkers stand to gain health insurance coverage.
In this case, the next big push will need to be raising public awareness about the law, and what will change (and what will stay the same). Over and over, studies show that people don't understand the law and how it affects them. A Kaiser Family Foundation poll in March found that 40 percent of those surveyed either thought the law had already been overturned, or were not sure. So part of making reform work well in New York is ensuring that people understand what it means for them: If I don't have health insurance now, what are my options? If I already have health insurance, how might the law affect my current coverage? If I'm a small business owner, what do I need to know?
It will also be important to make sure adequate consumer protections and supports are built into the Exchange.
- The individual mandate is thrown out, but the rest of the law stands. A number of national studies have looked at the likely effect of the mandate being struck down. Estimates vary considerably, but without a mandate, the number of newly insured individuals is likely to drop by 25 percent to 50 percent. So, instead of 1.2 million New Yorkers gaining health insurance, it might be only 600,000 or 900,000. That's still a big number, but a sizable portion of New Yorkers would remain uninsured, and more State-level innovation would be needed to expand coverage further. To date, Massachusetts has been the beacon for state-level action on health reform; if the mandate falls, the next opportunity will be for leading states like New York to experiment with creative solutions and become the next handful of Massachusettses. For example, New York might consider creating a State mandate for insurance coverage. Assuming that the subsidies created by the ACA are still in play to help lower-income people purchase coverage, a State-based mandate seems feasible under this scenario.
- Insurance market reforms are struck down, along with the individual mandate. New York State has already approved key aspects of insurance market reforms, including guaranteed issue (meaning that policies must be offered to any eligible applicant regardless of their health status or any pre-existing conditions) and community rating (which means that health insurers must offer policies within a given region at the same price to everyone, regardless of their health status), so if those market reforms are struck down at the Federal level, we will not likely see much impact here. But in other states, such a ruling could significantly affect coverage rates, pricing insurance completely out of reach for the people who need it most: those who have low incomes and who have health problems already. State-level action under this scenario will be critical to expanding health care coverage and keeping it affordable.
(Similarly, I should note that the Medicaid expansion included in the ACA could also be ruled unconstitutional, but given that New York already has very generous Medicaid coverage, the effect on our State's coverage rates would be minimal.)
- The entire law is struck down. If the ACA is struck down in its entirety, New York will need to make the most of the Federal funds already in its coffers to upgrade eligibility and enrollment systems for public coverage programs. But there would be few dollars and stalled momentum for meaningful coverage expansion and even for some of the payment and delivery-system reforms that have been picking up steam, like accountable care organizations and health homes.
I'm not a betting man, in general, and I'm especially not betting on this one, with the stakes so high and no clear expert consensus on what the Court's decision will be. If all or most of the law is struck down, we will be forced to tinker around the edges of a broken system that desperately needs a total overhaul, leaving millions of New Yorkers without the care they need to lead healthy and productive lives. In that case, I do bet that Americans will insist that the gridlock in Washington be undone so that a more popular compromise is designed quickly.