UPDATE: Supreme Court upholds Affordable Care Act

Adam M. Brufsky, MD, PhD, FACP

My initial thoughts are that the ruling is dead wrong. It is clear that Congress overstepped its bounds by ruling with the barest majority of votes on something as complex as this. Everyone was clear that it was not a tax at the time. However, the Supreme Court — also with the barest of majorities — has decided to call the regulation of inactivity a “tax,” even though nobody called it that. Therefore, going forward until the election, let us call it what it is: a tax on everyone who does not buy health insurance. It is a very regressive tax, generally affecting those who can barely afford to pay it — the young, healthy people with little money.

The Affordable Care Act does nothing to rein in costs. It imposes new, complex regulations — very few of which have been thought out — on 18% of the economy. Let us hope that the American people, in their judgment, realize this and have the congressional representatives, senators and the president who authored it tossed from office.

Jed B. Gorlin, MD, MBA

As a transfusion medicine physician at an urban county trauma hospital, I witnessed increased volume due to patients without adequate coverage due to job loss seeking health care at our county institution. The upholding of the Affordable Care Act (ACA) recognizes the importance of an equitable approach to expanding the safety net and reimbursing health care institutions in a more rationale fashion for the care they provide to the poor instead of behind-the-scenes cost shifting.

Although the ACA greatly improves access, it did not sufficiently address the root causes of health care expenditure inflation. The next, more challenging step is addressing the escalating total cost of care, which is unsustainable. Physicians must play a larger role in containing costs in a way that improves outcomes, as opposed to denying needed care. This means getting involved in the political process to ensure that care and quality are foremost in an era of reduced resources, which must address the disproportionately high percentage of our health care budget spent on administrative aspects of health care, as opposed to direct service.

Max S. Wicha, MD

I am delighted with the ruling. I think this is a very important step forward for our patients, particularly those with cancer. There are so many who did not have health coverage. This will enable them to get the treatments that are lifesaving. We also think this is a great victory for people with pre-existing conditions. Patients with cancer, many times, were denied insurance or offered insurance at such an exorbitant rates that they could not afford it. This will really help cancer survivors. I think for us as health care institutions, it gives an opportunity and a challenge. Now we really need to move forward to figure out the best way to give our patients the best care in a more affordable way by reducing costs and setting up more collaborations and networks. We have been working very hard on that already, and this gives us more momentum to keep moving in that direction.

Diane Meier, MD, FACP

The Affordable Care Act, with its aims to expand access to quality health care for all Americans, will positively affect health care delivery to the most needy and seriously ill persons in the United States. With increased access to care and much more attention to the quality of that care, more seriously ill persons and families will receive the palliative care they need to both reduce suffering and live longer, healthier lives. This benefit is of the utmost importance to the field of palliative care, as the patients we treat are the sickest, most vulnerable people turning to the nation’s healthcare system. Components of the ACA that are of utmost importance to people with serious illnesses of all types- at all ages include:

1. Insurers will not be able to deny coverage due to a pre-existing condition;
2. Insurers will not be able to drop a person’s coverage because they become sick;
3. There will be no lifetime limits on coverage, so coverage cannot be cut off once the bill hits a certain threshold;
4. Children up to age 26 years will be covered by their parents’ insurance, and
5. For everyone trying to avoid future serious illness, free prevention care is now covered.

The delivery of high-quality care is critically important to the patients we serve — Americans of all ages with serious and complex illness.  As new quality measures are adopted, new medical research funding is allocated and delivery systems are re-calibrated to meet patient and family needs, we welcome the opportunity to ensure that essential palliative care is brought to all our nation’s seriously ill patients.

Harry S. Jacob, MD, FRCPath(Hon)

By coincidence, the day before the ACA Supreme Court decision, I read an article in the June 25 New Yorker by Ezra Klein (www.newyorker.com/reporting/2012/06/25/120625fa_fact_klein?currentPage=all). It documented how politics had dramatically altered the predictability of the coming decision. Klein noted that shortly after Congress passed the ACA, “it was hard to find a law professor in the country who thought the law unconstitutional.” Moreover, Klein quoted a George Washington University professor, Orin Kerr, who had clerked for Justice Anthony Kennedy: “There is less than 1% chance that the courts will invalidate the individual mandate.” 

Well, 14 months later, the odds had become even after dueling campaigns by both political parties. The dueling will no doubt continue and will be energized by the surprising and determinative opinion of Justice Roberts, who found constitutional the individual mandate based on the federal government’s taxation authority. The term “taxation” — emotionally charged and politically divisive — will undoubtedly be a central issue in the upcoming election campaigns. I hope that the following data will somehow inform the debate: namely, the cost of health care in the United States is at least 30% higher per capita than in all other comparable developed nations, even though some 50 million of our citizens (until now) have no health insurance.

A significant reason for this dichotomy is the tens of billions of dollars we Americans spend annually to provide inefficient health care in emergency rooms to the uninsured — not to mention the economic (and moral) disaster of lost wages and even lives due the unavailability of preventive medical interventions for the uninsured. Thus, our population at large is already “taxed” to provide the extra funds for our uninsured brethren. If 250 million insured folks are providing tens of billions of wasteful dollars to the uninsured, they are already victims of hidden taxation that currently works out annually to a few thousand dollars per person. I look forward to the upcoming debate with hopes for a more equitable and efficient health care environment in the future.

Donald L. Trump, MD, FACP

This decision is important. It not only affirms that the ACA will proceed to implementation and, hence, will have a positive impact on access to medical care, it will favorably influence the availability of comprehensive care to cancer patients as well as increase access to screening and preventive services. In addition, it allows the important national conversations regarding continued improvements in how we organize and provide care to continue. I had feared that if the ACA had been overturned, there would have been chaos and continuation of a “business as usual” in health care. Business as usual is unsustainable.

Brian Bolwell, MD, FACP

The way health care is delivered in the United States needs to change. It is too expensive and it occupies too much of our annual expenditures. Trying to control health care costs is important, and it is also important to have every American have access to health care. I think upholding the ACA goes a long way to address both of those concerns. Much of the current debate that the Supreme Court had was whether it was constitutional to mandate that the vast majority of Americans be required to have insurance, and they ruled that it was. Much of the remainder of the ACA — which has not received as much scrutiny — involves many initiatives from Medicare that are already in place, such as reimbursing providers based on quality and performance.The oncology community needs to be aware of the importance of that part of the ACA.

We need to continue to define quality cancer care and how to deliver it as efficiently as possible. The issue of Medicare reimbursement evolving into paying for performance and paying for quality is a significant change for providers. It is really up to the oncology community to work in collaboration to help define those quality parameters better than we currently do. The other issue is delivery of efficient care. The oncology and cancer community has the opportunity to improve our efficiency. This should be a catalyst to do so.

Philip L. McCarthy, MD

The big impact for hematology/oncology and cancer centers such as Roswell Park Cancer Institute is in addressing coverage for clinical trials. This has been a big problem in that some insurers will not allow patients to participate in clinical trials, limiting our ability to advance the field. We can expect that now that this barrier to coverage for new and investigational therapies will be eliminated, the pace of treatment advances will pick up. Coverage for more patients is good; however, a major issue is how we pay for more technology. We will continue to face these financial issues as we get better at treating patients with newer pharmaceuticals and techniques that are expensive.

Victor J. Dzau, MD

The US Supreme Court decision on the Affordable Care Act adds much-needed direction on the issue of health care reform, even as there will likely be ongoing challenges. What is undisputed is that the law’s goals of increasing access to care and lowering costs are imperative, and we absolutely support them. It will now be incumbent on those of us in the health care delivery system to assure that such objectives do not come at the expense of quality, which is an equally important aim. We are already moving forward on this. Hospitals, health systems, payers and providers have been working to meet the requirements and the goals of the law, and this decision will accelerate those efforts. That is a good thing for everybody needing health care.

With expanded insurance coverage, more people will have affordable access to routine care through a primary care physician, have a greater ability to focus on prevention and wellness, and avoid utilizing high-cost emergency departments as their medical care. As a large health care system, we must now concentrate on ways to accommodate the potentially huge demand for primary care providers. We must also continue to focus on innovation, quality and efficiency. Although the Supreme Court ruling provides clarity, there remain many unknown factors that will affect how hospitals and doctors oversee care, particularly for the millions who will still not have health coverage despite the law’s mandate. Such details will take form as the law unfolds, and time will tell how well it is implemented. But I can say with conviction that increased access to high-quality, affordable care is a goal that absolutely must be achieved.

J. Robert Beck, MD

In one sense, the passage of the Affordable Care Act had the effect of moving the train out of the station when it comes to health care financing reform in the United States and put us on track toward a more universal system of coverage of health care financing. By upholding the individual mandate as something that the Congress has the authority to regulate through taxation, coupled with allowing states to opt out of exchanges and not be forced to take on an increase in Medicaid population coverage, the ruling actually could accelerate the discussion about a federal model in which individuals can purchase a federalized version of health care insurance. It might have the paradoxical effect of accelerating the pressure toward the federal government as a payer of last resort for more and more people.

Michael Neuss, MD

Many provisions of the Affordable Care Act are helpful to cancer patients. The right to purchase health insurance, which does not exclude coverage for pre-existing conditions, is important to survivors and those with active disease. Simply having insurance when facing cancer allows patients and their families to focus on treatment rather than paying for treatment. The requirement for insurers to cover usual care in the course of clinical research will increase therapeutic trial accrual, which — in turn — will accelerate the development of better treatments.