In the wake of the US Supreme Court’s decision to uphold the Affordable Care Act, physicians are speculating as to how this will affect their practices. Cardiologists, in particular, are hoping the ruling may provide the tools for both combating CVD and improving the health care system.
A landmark decision
The US Supreme Court ruled 5-4 that the mandate in the Affordable Care Act for all US citizens to purchase health insurance is constitutional. The court’s decision essentially upheld the entire health care reform law.
Chief Justice John Roberts read the majority opinion, which stated that a penalty for not purchasing health insurance should be treated as a tax that Congress has the right to levy according to its constitutionally sanctioned power of taxation.
The court also ruled that a provision requiring states to comply with new eligibility requirements for Medicaid or risk losing their funding is constitutional. States only lose new funds, not all of their funding, if they do not comply with the new requirements, according to the opinion.
“Nothing in our opinion precludes Congress from offering funds under the Affordable Care Act to expand the availability of health care, and requiring that states accepting such funds comply with the conditions on their use,” Roberts stated in the opinion. “What Congress is not free to do is to penalize states that choose not to participate in that new program by taking away their existing Medicaid funding.”
The Patient Protection and Affordable Care Act (ACA) was passed by Congress and signed into law by President Barack Obama in March 2010. Twenty-six states challenged the constitutionality of the insurance mandate. The Supreme Court heard 3 days of oral arguments in March.
Initial reactions
Cardiology Today Intervention Editorial Board member Kenneth Rosenfield, MD, counted the Supreme Court’s decision as a win.
Kenneth Rosenfield
“This is obviously a monumental decision, and I think it’s the right decision,” Rosenfield, who is also head of vascular medicine and intervention at Massachusetts General Hospital, said in an interview. “Overall, this has been a positive thing here in Massachusetts, and I think it will be a positive thing nationally as well. We need to now go to work to figure out how to implement it in a fair and judicious way — in a way that will actually add value to patients and enable us to keep all the good things in the American health care system while we tear back the things that are not adding any value.”
William Zoghbi, MD, FACC, president of the American College of Cardiology and director of the Cardiovascular Imaging Center at the Methodist DeBakey Heart and Vascular Center in Houston, agreed, noting that the ACA opens the door to improving the health care system as a whole.
William Zoghbi
“What we’re looking for is a more integrated system that provides good quality care and, most importantly, a way to come up with payment reform that would reward quality as opposed to volume and emphasizes value,” he told Cardiology Today.
Even so, obvious challenges exist, Zoghbi said. “There will be a lot of integration, but integration does not necessarily mean employment of physicians, and there will be different ways of integrating and improving health care throughout the country. There isn’t any ‘one system fits all.’”
Combating CVD
Although the impact of the decision on the cardiology field remains to be seen, American Heart Association CEO Nancy Brown issued a statement largely praising the high court’s stance:
“The historic decision handed down today will benefit America’s heart health for decades to come. Questions about the ACA’s constitutionality have overshadowed the law’s progress. With this ruling, that uncertainty has finally been put to rest."
In the statement, Brown also highlighted how the court’s decision allows for the “ACA to be fully implemented to help reach the AHA’s 2020 goal to improve CV health of all Americans and, more immediately, prevent 1 million heart attacks and strokes over the next 5 years through the Million Hearts initiative.”
Furthermore, Brown pointed out that the ACA sheds light on the importance of prevention — a cornerstone of curbing CVD.
“There are provisions in the ACA for emphasizing prevention and early screening, and this is very welcome. It will help with earlier detection and, most importantly, prevent disease, particularly if an individual has other identified risk factors. If you don’t have access to care, there’s no way to perform early screening and implement preventive strategies. If you only has access to care at the symptomatic stage, it’s usually quite late,” Zoghbi said. “Prevention is really key for good quality of life, longevity and value.”
“For individuals, the law will continue to provide screening services that help keep risk factors such as high BP, cholesterol, obesity and tobacco use in check. At the state and community levels, the Prevention and Public Health Trust Fund will continue to provide the tools and resources Americans require to eat better, be more physically active and live tobacco-free,” the AHA statement reads.
The ruling, Brown said, may also put to rest concerns for people who remain uninsured.
“For the 122 million Americans with pre-existing conditions, including the 7.3 million with some form of heart disease or stroke who are uninsured, this decision will likely be met with a great sigh of relief. No longer will they be denied coverage or charged higher premiums because of their health status. Beginning in 2014, these Americans will finally be able to attain the lifesaving care they desperately need at a price they can afford.”
Implications for cardiologists
Despite the potential benefits, cardiologists expect to face many challenges in the future. An important point of focus, which was on the radar screen before the Supreme Court’s decision, has been coming up with “newer payment systems that would be a win-win situation for health care and for sustainability of the health care system” and eliminate waste, Zoghbi said.
“From the ACC’s point of view, quality of health care is paramount, including appropriateness of use criteria, meaning use of appropriate testing or therapeutics in the appropriate patient at the appropriate time. We are focusing on quality in the health care we provide, but we want to work within a system that rewards the same.”
Rosenfield also shed light on how the Supreme Court’s decision affects cardiologists. For instance, he pointed out that people tend to emphasize areas for improvement while occasionally overlooking major strides in the field.
“A lot of health care cost is tied up in cardiology, per se,” he said. “We are a high-cost specialty, but on the other hand, we are a highly effective and high impact specialty. If you look at the past 20 years, the roughly 30% reduction in CV morbidity and mortality is phenomenal. In no other area of medicine has there been such an impact as we’ve made in cardiology and in CV care: we’ve reduced mortality, improved longevity and quality of life and we are, in the field of interventional cardiology in particular, the poster child for looking at outcomes and subjecting ourselves to the scrutiny of everybody else, including the media, and trying to improve ourselves.
“It is really important not to ignore the things in interventional cardiology and cardiology in general that we do right because we do have it right most of the time. There are few other specialties that are collecting as much data and doing as much in the quality arena as we are.”
Nevertheless, bottom line, he said, the ACA is good for patients.
“And what’s good for patients is also good for doctors. It will provide access and we just have to make sure we streamline health care so we keep the good things we have, which allow us to continue to innovate and improve as we have done over the past several years.” – by Melissa Foster, with additional reporting by Brian Ellis and Rob Volansky