Infectious disease doctors react to the Supreme Court’s decision to uphold Affordable Care Act

  • June 28, 2012

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.

“Most of us in the HIV community are quite elated that the court ruled in this manner,” Jim Raper, DSN, nurse practitioner and director of the HIV clinic at the University of Alabama at Birgmingham, told Infectious Disease News. “This helps continue the health care reform moving forward in a very positive way. We look forward to the time when patients have greater access to the health care that they need, and that providers of that health care get reimbursed for the care that they are providing.”

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 Supreme Court ruling upholding the Affordable Care Act as the law of the land is a significant victory for people with HIV infection and the public health of our nation,” Judith A. Aberg, MD, FIDSA, chair of the HIV Medicine Association, said in a press release. “The Affordable Care Act corrects the injustices of our current health system, which often denies health insurance coverage to those who need it most. Too many of our patients have died prematurely despite the availability of effective HIV treatment due to late diagnosis and poor access to health care services.”

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 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 U.S. citizens to purchase health insurance by 2014.

Perspective
Paul A. Volberding, MD

Paul A. Volberding

  • The Supreme Court today allowed the most important reform of American health care in our memory to proceed. The job is far from done and much effort at controlling the cost while improving the quality of care will be required. But now, with the expansion of care access to almost all citizens, that can at least begin. All persons and all parts of the healthcare system will be touched by today's decision. The infectious disease specialty is most definitely included in that impact. Electronic medical records in hospitals and offices will be required and can be used to improve treatment and reduce hospital acquired infections. HIV care will be tremendously affected as many patients will gain early access to Medicaid coverage reducing the demands on the Ryan White services which will continue to provide essential supports to retain patients in care, improving health outcomes and reducing HIV transmission. The Court's decision should be vigorously applauded for expanding care access even as we begin the next battle to control expenditures while simultaneously enhancing care quality and patient safety.

    • Paul A. Volberding, MD
    • Infectious Disease News Chief Medical Editor
Perspective
  • The United States Supreme Court, in a 5-4 ruling, upheld the Affordable Care Act’s (ACA) mandate, which requires individuals to purchase health care insurance. Many Americans were surprised by this ruling, perhaps with some justification. The Supreme Court disagreed with the reasoning for the mandate’s constitutionality, but still upheld the mandate with different reasoning. The Obama administration claimed the mandate was constitutional under Congress’ ability to regulate interstate commerce. Chief Justice John Roberts, writing for the majority, stated that Congress had the power to regulate interstate commerce, but could not force people to participate in it. Roberts concluded that Congress could, however, tax people, who decide not to purchase health care insurance.

    What does this ruling mean for health care in the USA? Quite simply, it is a game changer. This legislation will force tens of millions of Americans, who currently go without health care insurance, to purchase some form of health care insurance or pay a surcharge or extra tax to the federal government. This requirement will change insurance rates, pharmaceutical companies’ profits, hospital revenues and doctors’ incomes. Insurance rates may actually decrease as more healthy people pay into the pool, while hospital revenues and doctors’ incomes are, in the short run, likely to increase. However, increased scrutiny of doctors’ practices is also expected. Many physicians fear or now expect the additional loss of autonomy. Doctors worry that this step is the first of many towards a system, completely run and dictated by the federal government. People are also concerned that many will pay the surcharge or tax and go without insurance, so long as the tax is cheaper than insurance.

    The ACA also expands Medicaid greatly. The impact of this expansion will vary state to state. For instance, in New Jersey Medicaid physician reimbursement is currently very low. Therefore, Medicaid expansion may not change New Jersey Medicaid patients’ access to physicians. However, the expansion will increase hospital revenue and will provide prescription benefits. Pharmaceutical companies are expected to benefit. Together, it is hoped that the use of emergency departments and urgent care centers will decrease, since people will have increased access to medical care.

    The ACA, which was endorsed by the AMA, and other changes to the health care system are so-called reforms. To practicing physicians, they are seen as a take-over of our profession. More and more doctors are told by people with minimal medical training what test we can order or what medicine we can prescribe. Hospitals treat us, not like partners any more, but like cogs of a large machine. Physicians feel helpless and frustrated as their profession has evolved into a regulated, supervised job. We are being measured by outcomes related to short term costs, including length of stay and the use of generic drugs. Private insurers deny tests and procedures routinely, based upon their own made-up “guidelines.” We all have had surreal conversations, in which the person, who will approve or disapprove our decision, can’t even pronounce words like “antimicrobial.” In infectious diseases in particular, hospital antimicrobial stewardship programs have become very aggressive. Yet, the IDSA and medical societies have done nothing to help the practicing ID physician stand his/her ground. Doctors feel overwhelmed and outmatched. And no one in our profession has figured out a way to help.

    The near future of medicine appears to be corporate medicine. The new constraints, imposed by the government and private insurers, will force physicians to join large entities, which can deal with these organizations. Doctors will no longer work for themselves and it will be very hard to determine who is a good doctor. Doctors’ hours will be reduced, as will their incomes. In short, being a physician won’t be a whole lot different than being any other employee. We will get hourly rates with some incentive for working a little harder. There will be little incentive for a physician to become better, save the love of medicine. Of course, the corporation will judge us, not by our knowledge base or work ethic, but the cost per patient.

    One strange part of the debate on health care reform has been the absence of discussion about patient compliance. The press, academic physicians, especially those who write for the New England Journal of Medicine, and others have been critical of physicians. These reformers often cite data, which they interpret as doctors over-testing and over-treating. These reformers and critics, however, never talk about the American patient. Those, who are involved in chronic disease management, know very well that American patients’ adherence with medications and doctors’ appointments are poor. We all agree that improved adherence leads to reduced hospitalizations and reduced costs. Despite this fact, health care reformers do not address this issue. Hopefully, now that most Americans will have health care insurance, this topic can enter into the debate. Maybe then we can figure out why only 50% to 70% of HIV patients take their daily pills and devise an approach which increases that rate.
    • Stephen Smith, MD
    • Infectious Disease News Editorial Board member
Perspective
William Schaffner

William Schaffner

  • This Supreme Court decision is a very affirming decision for the prevention of disease, particularly through immunization. Millions of adults now will have access to first-dollar coverage for life-saving vaccines. We in clinical medicine and public health now will be able to raise awareness among adults about the crucial need to receive vaccinations without concern that financial constraints will be a barrier. The Campaign for Adult Immunization of the National Foundation for Infectious Diseases will participate vigorously in educating both the public and providers about this new opportunity for prevention.

    • William Schaffner, MD
    • Infectious Disease News Editorial Board member

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