The US Supreme Court today ruled 5-4 that the health care mandate is constitutional. It upheld the entire Affordable Care Act, with the exception that the federal government’s power to terminate states’ Medicaid funds is narrowly read. Chief Justice John Roberts read the majority opinion.
The Patient Protection and Affordable Care Act was passed by Congress and signed into law by President Barack Obama in March 2010. Twenty-six states have challenged the constitutionality of the law’s mandate for all US citizens to purchase health insurance by 2014.
In early 2011, Florida Attorney General Pam Bondi challenged the health care law on behalf of Florida and 25 other states. In August, the 11th US Circuit Court of Appeals ruled that parts of the law are unconstitutional, and in November, the US Court of Appeals in Washington ruled the law unconstitutional.
In November, the Supreme Court agreed to hear a legal challenge to the law. In March, the court held 3 days of oral arguments surrounding the constitutionality of the health care mandate.
Concerns and caveats
Endocrine Today spoke with experts to get their reactions to the decision and determine how the ruling will affect the future of American medicine.
“The very first thing that came to mind with this ruling is that the decision sets up a two-tier system in the US: Obamacare and the elite congressional care. The first thing the American public needs to do is command that Congress immediately come under the same care that the rest of us have,” John Seibel, MD, FACP, MACE, member of the board of directors for the American Association of Clinical Endocrinologists and an endocrinologist in private practice in Albuquerque, New Mexico, told Endocrine Today. “If not, we will soon see the erosion of care for the general public while our leaders have nothing but the best of care.”
As someone who will obtain medical care under the Affordable Care Act (ACA), Seibel said he is worried about the kind of care he will receive. In addition, the insurance companies’ ability to compete with the government (public) exchange is of equal concern because the government has always demanded deep discounts and the insurance companies will have no choice but to increase premiums to meet the costs. As a result, more patients will be forced into the public exchange.
“Soon, all patients will be in the public exchange, and insurance companies will only offer ancillary policies, as they do with Medicare,” he said. “The government will have control of our health insurance and we will have what many have been hoping for — a single-payer system.”
Jonathan D. Leffert, MD, FACP, FACE, chairman of the socioeconomic committee and a member of the board of directors for AACE, told Endocrine Today that, although in favor of the idea of expanding coverage, in terms of pre-existing conditions and dependents up to age 26 years, he worries about the ACA in relationship to the independent payment advisory board.
Jonathan D. Leffert
“There are concerns about penalizing physicians for non-participation in the Product Quality Research Institute (PQRI), which begins in 2015 and creates the value index adjusters to physician fee schedules, which modify payments based upon untested quality and cost of care profiles,” he said.
Leffert views the independent payment advisory board as an “ill-advised way of approaching the issue of reimbursement for physicians and others because it takes the issue into the hands of an individual group of nonphysician bureaucrats who basically make decisions on what will and won’t be paid for in the Medicare system.” In short, Leffert sees it as a “recipe for disaster.”
More patients, less providers
Another big concern among experts — especially endocrinologists — is a lack of physicians combined with an aging population, especially in the midst of the diabetes and obesity epidemics.
“Endocrinologists cannot provide all of the care to obese people, patients with prediabetes and diabetes,” Leffert said. “That’s going to have to be an effort among all physicians, particularly family physicians, internal medicine physicians and endocrinologists.”
Seibel has similar concerns, citing the switch to electronic health records (EHRs) and the demands of e-prescribing and meaningful use requirements as difficult hurdles for solo physicians and those in small groups.
“Between now and 2014, this will become even harder. In most cases, it will force physicians to become employees of hospitals, insurance companies or very large groups. This will be catastrophic for many physicians in small towns, which could cause an exodus of physicians out of small towns, making the shortage of physicians even greater. If an exception is made for a small town physician, it could result in more physicians migrating to small towns and a greater shortage of physicians in larger towns.”
The bottom line, Seibel said, is that there is a physician shortage in most places. Employed physicians are pressed to see more patients and already feel they are seeing more than they should. Additionally, physicians who have already adopted EHRs with meaningful use report that instead of increasing their productivity, EHRs decrease their productivity.
Lastly, Seibel said about 32% of US physicians are aged older than 55 years, many of whom are still practicing older than the age of 65 or even 70 years and are in solo practice or small groups. As their overhead costs continue to increase to meet the CMS and Obamacare provisions, their productivity goes down.
“This, coupled with the predicted increase of patients under Obamacare, will cause an even greater physician shortage,” he said.
In the long run, although Seibel said he had no intention of retiring in the near future, the Supreme Court’s ruling on the ACA has led to his decision to retire from seeing patients at some point before 2014, when the ACA is expected to take full effect.
“There is no question in my mind that Obamacare will exacerbate the physician shortage much more than predicted by anyone,” he said. “Unfortunately, I will continue to be a patient under this system, and I worry about the health care that I will be able to receive under it.”
In a statement from the American Diabetes Association in support of the ruling, Larry Hausner, CEO of the ADA, said, “This law eliminates health insurance discrimination against people living with diabetes and provides access to affordable, quality health care and prevention programs needed to curb the current diabetes epidemic and prevent its devastating complications, including blindness, amputation, heart disease and kidney failure.
“Every day, the American Diabetes Association works hard to expand access to affordable care to prevent, delay and slow the progression of diabetes,” Hausner said. “Upholding the law is a major step forward in our continued fight as we work toward full implementation of the Affordable Care Act. People with diabetes, and all Americans, will no longer be denied access to the health insurance they need, will not have their insurance run out when they need it most and cannot be discriminated against based on pre-existing conditions, such as diabetes.” – by Stacey L. Fisher